Can a Robotic Joint Replacement Provide Better Results?

Podcast Transcript

Music (Intro).

Speaker 2: 0:13
Hello, and welcome to the “Bone and Joint Playbook: Tips for Pain-Free Aging”, with Dr. John Urse. Dr. Urse is a Board-Certified orthopedic surgeon, with over 35 years’ experience in the Dayton, Ohio area. He is also a clinical fellowship- trained surgeon in total joint replacement from Harvard.
Today’s topic is “Can a Robotic Joint Replacement provide better results?” Today our special guest is Dr. Chad Weber, who has done over 1000 Robotic Joint Replacements in the Southwestern Ohio area. This episode is brought to you by:

Speaker 3: 0:47
‘Ted’s authentic Greek salad dressing and marinade’: It’s healthy, gluten and sugar-free, dairy-free, and low sodium. There are no additives, and it is delicious. You can find Ted’s in Dayton, Ohio at Dorothy Lane Markets, Health Foods Unlimited, and Dots markets. That’s ‘Ted’s authentic Greek dressing and marinade’. Thanks, Ted.

Speaker 4: 1:04
Well, hello folks. It’s Terry O’Brien here, Tri-Level Records. We’re back with another episode of the Bone and Joint Playbook, with Dr. John Urse. I’m going to let Dr. Urse introduce his special guest. Doctor, take it away.

Speaker 5: 1:25
Well thanks, Terry. We have another cutting edge topic today. We will be talking about robotics in total joint surgery. Our guest is my partner, Dr. Chad Weber. He’s a Board- Certified orthopedic surgeon. He also has fellowship training in Trauma and Adult Reconstructive Surgery. He is also one of the pioneers in the Southwestern Ohio area in robotic surgery, having just hit the 1000 mark on total joint replacements, which is quite an accomplishment.

Speaker 4: 1:56
That’s a lot of joint replacements. Okay, so hello Dr. Weber.

Speaker 5: 2:00
How are you?

Speaker 6: 2:00
Good, thank you. Great to be here!

Speaker 5: 2:02
Well, Terry, let me talk a little bit about our topic today. First of all, robotics and artificial intelligence (AI) help people do their jobs better. In orthopedics, robotics help improve the way surgeries are done. The robot is controlled by the doctor, and allows the surgeon to combine their knowledge, experience, and judgment with the precision of a robot in orthopedics. The use of robotics, including Partial and Total Knee Replacements (TKR), Total Hip Replacements (THR), and leg realignment procedures for deformities are what we’ll be talking about today. Dr. Weber, I’m going call you Chad, because it’s a podcast. What are the benefits of using robotics for Total Knee and Total Hip Replacement surgeries?

Speaker 6: 2:50
Dr. Weber: I think the main reason I started doing robotics was a lot of the implants are the same. Also, we find in today’s society we’re operating on larger people, and you’re trying to somewhat look for a way to separate yourself and get good outcomes, somewhat better than some of the other guys that are doing in practice. I mainly started doing robotics because I wanted my patients to do better, faster. Everybody wants to be better and faster. Using these implants in larger people, we have to make sure that we put them in right. So simply, in general with robotics, it allows more reproducible placement of implants, both in total knees, partial knees, and total hips. I think that’s really important with the patients that we’re doing today. No one wants early failures, and I would say from the research that we have up to this point with robotics, it does show that there’s less early failures, and better reproducible placement of the implants, on basically total knees, partial knees, and total hips.

Speaker 5: 3:52
Dr Urse: The big take home points would be, ‘does this improve accuracy?’ Which it sounds like it might. Does it improve speed, which gets people off the table sooner, with less bleeding, less complications with a more expeditious surgery? This should improve patient outcomes.
I think we wanted to wonder why are we interested in doing Total Joints better? Well, the numbers in the United States are a little different for hips and knees. Most people like their hip replacements. They get up, walk on them quickly, and they’re pretty thrilled losing a stiff hip. Also, how quickly they can move the new one and get around better. Total Knees are a little different. In fact, in the United States, we do over 700,000 total knee replacements per year, but over 20% of people are dissatisfied with their knee replacement. What do you think some of those reasons are, Chad?

Speaker 6: 4:41
Dr. Weber: I think it’s the rehab is often harder than what they anticipated. It’s continued pain. I think doing a primary total knee replacement, especially somebody who has had trauma and has had previous surgery on that joint, may be a little bit different patient than somebody who just comes in with regular arthritis versus post-traumatic arthritis

Speaker 5: 5:00
Dr. Urse: Because they may have what, scar tissue? .It’s kind of like that knee’s already had trauma to it, and it’s having more surgery, which is then more

Speaker 6: 5:07
trauma.
Dr. Weber: Correct. Sometimes it’s a lack of post-op physical therapy, where the patient is not necessarily motivated enough to go do the exercises. I would say, when I think of total hips and total knees, therapy’s important in both, but much more important and much more grueling in total and partial knees, than total hips.

Speaker 5: 5:25
Dr. Urse: Well, I’ll take the patient’s side of this equation. You mention things the patient’s not doing, that they should do. But I think the surgeons have some fault also. Looking at TKR’s, maybe some of these are too tight or a little loose; people feel like their knee wobbles, or gives way. The implants may be too big or small, sized incorrectly to fit them. I tell people, if you wear 8 1/2 shoes and you have to go around with size 8 or 9., it’s not really an eight and a half. Your sizes on your implants may over hang the bone edge and not be as accurate as they could be. And there are some, some specialized components that are made to be patient specific and made to fit your knee perfectly. So, I think that the doctor has some responsibility, but I think the patient has some responsibility and a combination of those two um, factors give you either a good or maybe a less than optimal outcome. But I think that makes all of us wonder if there is room for improvement in trying to get that number down. Unfortunately, with the trends we see in the United States because of baby boomers, obesity and the aging population, it’s anticipated by 2030 we’ll be doing 170% more total knee replacements, which means if 20% of 2 million people are unhappy, that’s a whole lot of dissatisfied people. Yeah, so I think that improving accuracy and using some of these robotic technologies might be a way that we put it in a little better, so it feels better. Then we can encourage our patients to soldier through that post-operative therapy, and discomfort.

Speaker 6: 6:58
Dr. Weber: I agree with you a hundred percent. I think there’s patient factors, there’s position factors, whether you’re using a robot or not, there’s an art to putting in a total hip or a total knee. Going through training we get to see various people put total knees and total hips in. I think that that is part of the art of doing a total hip and a total knee. Some people like them really, really loose. Some put total knees in a lot tighter than others, where they almost really squeak when they’re moving through the range of motion. Those people are obviously having a little bit harder time getting their motion back. But I think finding that perfect knee is something that I’ve looked for a long, long time. I think when I’m done with the end of a case, when I’m done with a robotic case, I’m much closer if not there after doing a robotic knee than I ever was not using the robotic stuff. It feels balanced, it tracks better, it just seems like a better total knee. I would say I feel like my results when I did 50 patients with one and 50 patients without one, the people who I did robotically far and above recovered much more quickly. The range of motion in a total knee that I didn’t use robotics was probably at two weeks, somewhere between 70 and 80 degrees, and I thought that was great. With robotics, I would say it’s not uncommon for people to come in at 95 to above a hundred degrees range of motion, and that has to do with just better biomechanics. Number one, putting them in perfectly or better. And then two, I think using the robot, there’s much less soft tissue trauma during the case. Less retractors in, less retractors out, not necessarily shorter time of surgery. I think that comes with doing more and more cases, but I think that those two things together really lead to a much better result.

Speaker 4: 8:51
Terry: Let me jump in here really quickly. I think we’ve gone pretty far into this, but as somebody who’s not a doctor, I’m always curious whether a robot is conducting this surgery? How does this thing work? What is going on? Can you explain that a little bit? Are you just sitting in the background during the surgery?

Speaker 6: 9:13
Dr. Weber: There’s three types of robotics involved with total joint replacements:
1) There are passive systems where you basically do everything. It’s like a guide system where human error can still occur during the case.
2) There are semi-active cases which are kind of like the Mako, which is the one that I use. It uses haptics. It’s a saw attached to the end of a robotic arm. Going into the case, you take registration, we do get a preoperative CT scan in the surgery, you actually confirm the position of the patient with that CT. Then they merge. Then what it does is make your cuts, and those cuts are planned. You know the size of the implants going in, though you may not know the exact thickness of the plastic. The robot prevents you from cutting the MCL (Medial Collateral Ligament). I don’t really put any retractors at all when I do that case because the robot will not let me go outside of those lines.
3) The active ones are where you sit in the corner and you push a button and you observe what it does. But the robot really does all of the surgery.
I would say most of the robotic systems that we currently use in orthopedics are either passive or semi-active. We’re still doing the surgery, we’re in there, we have control of the robotic arm. Unless we pull the trigger, then it’s not cutting. But if we pull the trigger, it’s only going to let us make the perfect cut.

Speaker 4: 10:40
Terry: It is more or less a safety guide, as it’s not going let you stray. It’s going to give you exactly what you wanted.

Speaker 6: 10:46
Dr. Weber: If you want to cut it one degree, it cuts at one degree. It does not cut at three. It does not cut at four. It cuts at one degree. So, it’s important for alignment. And you know, when we do that with the replacements, we do two things:
1) We take out the arthritis, and we realign them because they’ve developed a ‘bowed’ leg or a ‘knocked’ knee. We don’t want to allow the implants to wear out quickly… if we just take out the arthritis but we don’t correct a deformity, they will fail and they will usually fail fast. So, the realignment is just as an important part of the surgery as taking out the arthritis.

Speaker 4: 11:20
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Speaker 5: 11:22
Dr. Urse: Let’s talk about what’s called a well-balanced knee. i.e.one that feels like it’s moving well in a straight or a bent position. When you take your knee from a fully straight position to a bent position (extension to flexion), it has to move through an arc of motion smoothly. If it feels wobbly when your knee’s bent and you go to stand up, then that little piece of plastic between the end of the thighbone metal and the upper shin bone metal isn’t thick enough. A patient may say their knee is giving way or doesn’t support their weight as they stand. What can prevent this? A robot can tell in surgery before the knee is replaced that it may be loose or wobbly in a flexed position. We can adjust that by putting in a thicker plastic spacer, much like we put a shim underneath a short table leg. Or we have the ability to see that before we make the cuts, so the bony spaces or gaps between a straight or bent knee are equal and gliding smoothly. That is what the robot lets us do. And though I use a different robot that Dr. Weber uses, the ROSA system guides precision knee replacements using a different company’s implants. Total knee and hip implants all look pretty similar, just like a Chevy or Ford carburetor look alike. They get you where you need to go.
When we do our preoperative or intraoperative planning, we see can see in advance if it’s going to be too tight when they bend their knee. We can move the intended placement of the implant up or away from the other bone, or add rotation to make more precision adjustments. Some people who are really bow-legged look like you could throw a football between their legs. Those people, we used to put their knee perfectly straight after surgery when we had computers for alignment, but not robotics for balancing the gap. And though the hip to ankle alignment appeared straight, they all weren’t perfectly happy. We found later with the robot, the more precise indicators showed us how balanced the knee would be as the knee moved thru an arc of movement. Actually, we found out that a degree or two, just a little bit of bowing was actually perfect for that person’s mechanics. And when he says a balanced knee is a happy knee, that means as you straighten and bend it, it’s not too tight, it’s not too loose, and it feels as good as it can.
Remember, these are not normal knees, they’re fake joints, right? They will never feel exactly as your former native knee. Metal and plastic coating are now moving smoothly inside your joints. For instance, your kneecap, which you feel as the round silver dollar-size bone on the top of your knee, gets replaced with a piece of plastic on its underside to replace the arthritis there. Also, it may feel unusual to kneel or do gardening on your knees. We allow people to do it, but they don’t have to.
Finally, my physical therapists tell me what Dr. Weber’s eyes are telling him; that your people with the robotics are doing better than some of your prior patients. They’re further along with motion, they seem happier. They still hurt when they bend and we don’t sugarcoat that postoperative pain that they’re going to have. We use ice and multimodal medicine control. We give them inflammation or muscle-relaxant medications, and plenty of pain medicines if you need them.
A new topic…Dr. Weber, if a patient were to ask, “are there any extra incisions needed for this robotic surgery? Will I have these pins sticking out where you’re putting the markers in with your antennas? What happens with the process of doing a robotic joint replacement?

Speaker 6: 14:40
Dr. Weber: With the system that I currently use, with a total knee, we have to find a way for your knee and its position in space to be able to talk to the robot. Most of these communications are sent thru antenna arrays. That usually requires us to put some sort of pins either in your tibia and your femur for a total knee or partial knee replacement. For a THR, into your pelvic bone so that we find a way to communicate the position of your hip joint and robot in space preoperatively. We do a CT scan for the surgeries I do, while other systems use preoperative x-rays. We get a CT scan of every hip or knee prior to surgery because that’s what we use to do our preoperative planning. That’s what we load onto the robot, so that in surgery those specific points on your knee or hip can scan your femur and tibia, and that it matches up with the CT scan. When those two things match with precision, that’s where the accuracy occurs. But it’s garbage-in, garbage-out… if you put poor bony landmarks into the robot (garbage in), your data is flawed (garbage-out). So, if you’re not matching it up, it’ll never match up, the robot won’t let you proceed. So, it brings in the precision. As far as intraoperatively and hips, I tell people they’re going have two incisions, a small one up on top of their hip by their pelvic wing bone, about an inch long. That is for your array, or antenna trackers to talk to the robot. Then their regular surgical incision on the front or side of their hip.

Speaker 5: 16:20
Dr. Urse: To summarize, small pins hold a little antenna that the robot sees with a camera. Then, bony anatomy points are registered by the surgeon in the beginning of the case, which lets Dr. Weber or myself adjust how to place that hip or knee implant in the proper position for that patient. Each patient may have some differing anatomy. Some of the hips are shallow, as those born with a shallow socket for the hip ball, as seen in hip dysplasia. Other hips have a deeper socket. Whatever anatomical variants are seen beforehand, we can adjust optimal location of implant to lessen any chance the hip could ‘pop out of place’ or dislocate. We can assure near equal leg lengths.

Speaker 6: 18:03
Dr. Weber: I think in bigger or more obese patients, it’s super important and definitely improves the accuracy. Another thing in my practice is I used to do a lot of Trauma. So people have a ton of hardware in their knees from plates and screws, nails, etc. Also in their hip, from acetabular or hip socket fractures or hip fractures. Can we replace that hip without having to take out all that hardware? Robotics allow me to know going in, I’m going have to take out this screw or that screw. And a lot of times there’s not necessarily normal anatomy with hardware in there. So, the normal anatomy is based off the CT scan and often they’re compared to the opposite side. Having robot allows me to do surgeries that are much higher level of difficulty, that I would probably shy away from doing in the past without robotic guidance.

Speaker 6: 19:03
Robotics allow me to walk into a case with a preoperative CT scan and have a much better plan going into the surgery. As a surgeon, I am much more competent and at ease going in there, feeling that the patient’s going to have a good outcome.
. Dr. Urse: We can compare this to sailing. If you had a chart and you said, I’m going from this island to that island, as the old saying goes, “if you don’t know where you’re going, you’re bound to end up somewhere else.” Surgeons like to have plans. We like to take the mystique and the surprise out of a surgery as much as possible, and go in to each case with an idea of what we’re going to do. But for the most part, as much of it we can have planned ahead, the better. just like that, that captain on the ship, let’s map out the reefs and trouble spots and get to auto-pilot to get there safely.
I think something patients want to know is when we put in a hip or a knee, can they walk on it right away? Is this bonded with cement? Is it something I can put my full weight down? Is it strong enough to not fall apart? What precautions would I have after surgery?

Speaker 6: 20:36
Dr. Weber: I let my patients fully weight- bear as tolerated, unless their bone is super bad in surgery or something occurs.

Do you mean soft like osteoporosis, that kind of thing?

Speaker 6: 20:49
I would say 99% of my people I let weight bear as tolerated.

Speaker 5: 20:54
Do they need a crutch, walker, or a cane?

Speaker 6: 20:57
Dr. Weber: For hips and knees, I would say most people are on a walker or a cane for anywhere between two to four weeks. That is the norm.

Speaker 5: 21:06
Dr. Urse: Really the goal is don’t fall. Use whatever is best for your walking and living areas. A walker is safest and has most stability. We did a podcast on having surgery, and moving your dog leashes, throw rugs, and getting a grab bar in the shower, can make your home ready for a procedure that you’re homebound for a bit Plan where to sleep. Will I have to go up and down steps to get to bed? Can I outfit my downstairs to sleep for a week or two? Who’s will help me with medications, ice, and toileting? All these things have to do with things we try to plan on the front end, in the preoperative period.
We send educational materials in print, via text messages, and videos or classes. Also, nutritional info they may need to optimize healing, and what kind of environment they will recovering in. We don’t want 10 cats in the room to get a wound problem around your incision.
Arthritis is a chronic condition that develops over many years, and planning for surgery makes this an elective problem, not an emergency. Take time to arrange for someone to be in your home for at least a few weeks after these joint replacements.

Speaker 4: 22:29
Terry: One question that popped in my mind with a robotic knee and hip replacements. Are the manufacturer reps in the room with you to make sure all the technologies are going correctly? How many people are in the room during a robotic?

Speaker 6: 22:47
Dr. Weber I would say for the robot cases, there’s always an MPS, which is a person who takes care of the robot. They run the robot, and fix any glitches with the robot. They’ve been trained, they’ve specifically work with that robot. They help with data that allow for doing the balancing of the implant positioning. When we talked about balancing the knee earlier, like making it feel right, there’s certain things that we can adjust intra-operatively with the implants. The technicians are the ones that make those adjustments on the screen and they help us bring those numbers to where we want them for optimal placement. So there’s an MPS in my room, there’s one implant company rep, there’s a surgical scrub, myself and one of my PAs, and then the Anesthesiologist.

Speaker 4: 23:28
Terry: So, remind me if I’m using a Mako robot, then I’m using Stryker components for my replacements. The ROSA (Robotic Orthopedic Surgery Assistant) robot uses Zimmer-Biomet implants. Two of the biggest implant companies in the world.

Speaker 5: 23:37

Speaker 6: 23:39
Companies at this point

Speaker 5: 23:40
Dr. Urse: I use a Rosa robot, which has the robot place cutting guides precisely to remove the bone spurs and worn cartilage from arthritis, in a planned balanced fashion with the surgeon doing the sawing. Intra-operative checkpoints validate the accuracy using the robot to assure the bone cuts match the intended construct. Much like placing a bubble in a level on a painting to be sure it’s just perfect. In the end, the goal for the Total or Partial knee replacement is to balance the knee in the proper alignment that we talked about. And there’s different ways to get to the end of the surgery. How we get to grandma’s house might be this road or that. But any method that uses cutting-edge technologies like robotics in conjunction with a Surgeon’s expertise and skill will make that joint best for the patient. That’s the art of medicine.

Patients have to do some of their own homework when deciding who will do their Joint Replacement surgery. If you’re having a simple tonsil surgery, you might go see any ear, nose and throat (ENT) doctor, because everybody does tonsil surgeries. But not everybody does robotic joint replacements. Not every heart surgeon does a great number of heart valve surgeries.
When you need a more in- depth surgery, it’s worth doing your homework as a patient consumer. A patient can ask, ‘How many of these have you done?’ Ask your friends, physical therapists, or primary care providers who they know for specific surgeries. It’s much like getting a recommendation for a restaurant. Word of mouth helps. Certainly, Dr. Weber’s extensive track record speaks volumes.
Improving patient outcomes, satisfaction scores, and longevity is what we need to strive for, especially when fair number of Total Knee outcomes are less than satisfying. Will Robotics be the answer? Time, especially 5-15 year follow-ups will be needed to know. We don’t want to say we’re going from 20% dissatisfied patients to zero. But we certainly want to knock that number into single digits. We want to do everything on our end to make that knee as happy as it can be to last as long as it can.

Speaker 4: 26:28
Terry: If I’m looking for, doctor say, to get a knee replacement, are there ways of finding a robotic knee surgeon? And then follow up question is, should I be worried about what technology they use? Are they all the same or is there one better than the other?

Speaker 6: 26:47
Dr. Weber: I think you want to look for somebody who is doing robotics in some form or fashion. At the end of the day, you want whoever doing your surgery to be comfortable with the way that they do it. Whether you use one system or another, I think that means you’re using technology that’s giving people the best chance for better results and recovering faster. I think you go talk to the surgeon and you just ask them to explain what they can do for you, and a lot of it has to do with their thought processes. For me, I tell people I try to learn from every case. There is no doubt that the Total Knees that I put in this year are better than the ones I put in two years ago. And I was using robotics two years ago. But that’s just the learning process and you keep on looking for that perfect knee or that perfect hip. And I think we’ve been close. I still think there’s things that we can improve on. Some of that may be through increased use of robotics, or it may be through some of the approaches such as anterior, posterior, or side hip incision locations. As we learn, just doing things a little bit differently, if results improve. It’s little things that sometimes make the difference.

Speaker 4: 27:48
Terry: So, Dr. Urse, I know we’re coming to the end of this podcast. Are there things that we haven’t got to that are important messages we want to talk about?

Speaker 5: 27:56
Dr. Urse: Terry, I would tell people that, as Dr. Weber said, you want to do your, your homework on the front end to find the right doctor to do your surgery. The right hospital system, one that is on your insurance plan, including anesthesia care that may or may not be in your network. Plan for your recovery, and realize your therapy will take an effort on your part to get a great result. Also, we want our joint replacement to last a long time. Thus, a hip or knee replacement shouldn’t be run or jumped upon. These are fake joints. Feel free to walk, play golf, you can swim, ride bikes, and do a lot of things. But you don’t want to fall out of a tree or off a ladder, or you’ve now broken your thighbone above your total knee or below your total hip replacement. That’s a mess for everybody. (Dr. Weber’s trained to fix that).
These are procedures are still early in their evolution, i.e., few robotic results are available beyond 5-10 years. They appear to be accurate, efficient, and, but we need to continue to collect data to follow outcomes. For now, the short- term results are good. They need to continue to be analyzed and stand the test of time.
Finally, we always want people to tell us if they have any allergies to nickel or metal. Hip and knee implants are metal, usually alloys of cobalt-chrome, a fraction of nickel, or titanium. A small group of people may have earrings that cause rashes, itching, or break out their ears. Some of the partial dental implants are made of nickel. If you have an allergy to that type of metal and we put it in your knee or hip, you’ll never be happy, because it’ll always be a little swollen, a little sore. You and your surgeon will be dissatisfied and wonder why it’s not doing as well as it could.

Speaker 4: 29:59
Terry: One of the final questions that I had, “I don’t know how to pick a good surgeon?”. I would not have the first clue? Do you just go to the doc your primary doctor tells you to go to?

Speaker 5: 30:28
Dr. Urse: Certainly, primary care providers are a good start. They’ve had other patients who have these surgeries done. You may have had someone in your family have another procedure by Dr. Weber or one of our OA partners. Check out OADoctors.com to review our providers and their specialty areas. Our group is rather diverse. There are online and review options for people to look at. And word of mouth helps, just like that restaurant we talked about.
Thanks again to our sponsor, Ted’s Authentic Greek Dressing.

“The Bone and Joint Playbook” podcasts are available on any place you listen to podcasts, ie Apple, Spotify, and I-Heart Radio.
Also, on the website DrJohnUrse.com
We appreciate having Dr. Weber come and spend some time and Terry, as usual, a great job with Tri-Level Recordings.

Speaker 4: 31:35
Well, thanks, Doc, I appreciate. This is Terry O’Brien. We’re tri-level productions, here with “The Bone and Joint Playbook, Tips for Pain-Free Aging” with Dr. John Urse. We’ll see you again soon.

Speaker 7: 31:45
Please join us again for another episode. Please rate us on your podcast site. This has been a production of Doctors Unmasked, produced by Terry O’Brien.
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