Dr. Bertrand Kaper talks about S+N robotic technology in ASC. The small footprint, portability, capital efficiency, image free smart mapping, make CORI™ System ideal for outpatient surgery.
So the next topic we're gonna discuss is advanced technology with Corey handheld robotics and journey to knee implants. I'm Doctor Bertran Copper from Scottsdale Arizona. So this is gonna be a very high level overview of journey two and Coy robotics. Um It's certainly beyond the scope of this talk for me to get into all the details that I think us as end users need to be aware of when we make decisions in terms of implant selection. Um So I'm gonna hit some of the highlights. Uh So this is a system uh a portfolio where, you know, we as surgeons can choose anywhere from cruciate, retaining to bi cruciate, substituting and even different polyethylene options which continue to expand with the media pivot type options that are coming uh to uh to the market as well. Um And uh short stems for revision uh circumstances or severe osteoporosis. So that it's basically a portfolio that allows us to cover everything, uh soup to nuts from implant selection just to review a little bit of from a physiologic standpoint. This is an active uh uh demonstration of what a normal knee does uh through the uh flexion extension arc and the details in terms of what's happening in the different positions are outlined on the left of the slide. So I really just had people get a visual of what the normal knee does with the combination of media pivoting translation. And that differs in terms of the different positions of flexion. So as we move forward and or I should say, look back first at what a conventionally designed totally does or how it is laid out. Uh There are some highlights I think need to be considered. So symmetric joint line uh conforming uh concavity, convexity of the femoral tibial uh components as it relates to the polyethylene design. And then in a uh post your stabilized design, a a deep poster cuss to help the patient gain deflection to avoid the paradoxical uh rollback uh that occurs with many traditional knee systems. So if we look at what the normal knee, the non arthroplasty knee on the left is doing versus what a traditional conventional total knee might do in a uh live simulators uh situation. Uh You know, you see that the conventional knee really does not replicate the motion of the normal human knee. So when we as arthroplasty surgeons are trying to replicate uh normal knee kinematics, we need things in our tool chest that allow us to do that. And the number one variable right here that I'm outlining is the design of the implant itself. So it's uh it's kind of like animal farm. All you know, all animals are not created equal, all implants are not created equal. And I think it's important for us as uh knee surgeons to acknowledge this and look critically at which implant will allow our patients the best opportunity for success. So when it comes to the journey to design specifically, uh again, this is based on life mod simulators based on MRI s of the normal human knee. Um The the idea is to replicate the through the implant, the normal human knee, not through the, you know, not designed based on the patient C T scan or MRI scan of a disease model, but actually off of a healthy knee model. So again, it's kind of beyond the the scope of this talk to get into all the details, but really just simple things like uh the three degree various joint line of the proximal tibia, the P access position. I mean, these are all variables that will drive the success of what the patients report. In other words, the focus that we've, you know, really been going after as far as improving patient reported outcome scores um is enhanced if we are using a des design, a knee design that allows us to replicate the normal human knee. So if we then go back to the a video comparing again the normal knee on the left, but this time the journey to knee, this is the crucial substituting design we see a much more normal replication of the normal human knee function and movement as far as where the pivot occurs when there's posterior translation, which is beyond 90° of reflection. And so, through implant design, we're already giving our patients to step up in terms of the ability to expect normal knee function. So that's from the implant standpoint, we then move to the technique standpoint. And in other words, how do we as surgeons successfully uh engage this uh the the implant and we can do that with traditional knee instrumentation. Uh But as a uh robotic user who have been a robotic user now for almost exactly 10 years. And it is uh to me more information to help me make better surgical decision makers. So I'm just gonna go through this fairly quickly so that we also have the time to uh discuss this actively. But if you, if you really think critically about what conventional instrumentation does, it limits us to uh focusing just on the static anatomy, uh bone and alignment issues, we then make our prescribed cuts. Um And then we are now left with the situation. Um to that we, we it's reactive, as I like to say, in other words, the dynamic anatomy, the soft tissues that we need to use to address, to balance the knee. We've created a circumstance where it's completely reactive as opposed to proactive, which is what robotics really does. So, you know, we've all in our training, uh had it, you know, beaten into our brains in terms of how, what's the best technique to balance the knee if it's loose inflection, titan extension, et cetera, et cetera, all the the algorithms that we go through. But we can now do this on the computer based on a proactive model with uh Corey robotics. So, you know, us with our old fashioned drills, saws to me that is truly old fashioned in terms of what we have access to uh a at this day and age. So ideally, uh incorporation of robotic technology would allow us to become better surgeons and hopefully allow our patients to expect better results which translates to better patient reported outcome measures. And that's really the holy grail. I think that we'd all admit that we're that we're chasing. So with robotics, uh we're using uh integrated system of, you know, computer engineering, uh biomedical engineering, uh robotic engineering to basically allow us to do real time mapping of the knee. And we'll go through the live uh video demonstration if you haven't seen this. But it's a system that we are still in control of as surgeons in terms of our decision making interoperate. So again, most important point that I want to make about this is that core robotics allows us to proactively do our total needs, we can incorporate gap balancing with measured resection um for soft tissue balancing. And when it comes to the issues of limb alignment. Again, that's individualized based on what the surgeon wants to do. Is it neutral? Is it kinematic? Is it constitutional? I personally um will go down the constitutional alignment path with my patients, but it allows us as surgeons to individualize the situation. So we're gonna play this little video here. Uh There we go. Betting videos in my talks was always the most daunting part historically, but uh COVID has allowed me to conquer that fear. So this is what uh uh was mentioned earlier. Uh It's a small footprint. This is basically an arthroscopy tower that we bring into our total joint operating room. Um And so it's not a big footprint. So in survey centers uh where the O R footprint is smaller, it's that there's still space for us to be doing this uh with this advanced technology. So this is just the registration process uh that we go through after we place uh the thermal arrays and the tibu arrays with the checkpoints. Uh We gather information about ankle center, about knee center and hip center to allow us to uh assess what the patient's preoperative alignment is. Um And so again, just rotating the hip here demonstrating the pie graph collection and we go through collecting static position. This is a nonstress range emotion just telling the computer what the knee does on its own. And then we have this small ball tip probe that allows us to do surface mapping. So we do not have to rely on preoperative advanced imaging such as C T or MRI. This is all intraoperative data that we collect that goes very, very quickly creating the three dimensional model of the distal femur and proximal tibia. We can then translate this to implant planning. So this is uh the measured resection part of the planning that Corey allows us to do in real time. We then incorporate soft tissue data which then allows that hybrid of gap balancing, measured resection. We can do all the balancing as the two bottom graphs show. Uh so that we know our knee is balanced, not just at 0 90 but actually throughout the entire arc of motion, we then go back and do checkpoint verification. And then we use the computer guidance to do our bony resection, which can be completely done with the Burr or a combination of Burr and saw depending on surgeon preference to basically create the the structure on the distal theme on the tibia and the proximal tibi that exactly matches what we laid out in our computer plan. Allow us to go ahead and put in our implants, take the knee through a full range of motion to make sure we know what the range of motion is stress, the knee inter operatively, we're not relying on our field, which historically has not been very good uh to get all this data about how we have done. So it's a tool that allows us to proactively plan execute and evaluate in real time uh how we do totally arthroplasty. So from my standpoint, more information makes me a better surgeon because I have better information to make decisions based on. And again, these are incremental, you know, changes half millimeter, half degree precision that we simply cannot touch when it comes to um standard conventional instrumentation. And then I mentioned the issue about uh footprint, very small and uh ease of uh moving this uh unit from 10 R to the next. So, um that's my formal didactic part of this Doctor Crystal. Do you? Uh uh First of all, are you using robotics in your A S C for your total? Yeah, we have a, a in our A S C that we use uh for a lot of our cases uh where we have to be slightly selective uh just because of disposables. Uh but we try to use it when we can, but I would imagine that if you had your, had your choice in the ideal circumstance, you'd use it for every case. Is that an accurate uh presumption on my part? Yes. Yeah, for sure. Uh We, we've really come around to it. Uh Both myself, I tend to be a little bit more uh forward thinking, I would say. Um I have a couple of partners uh who tend to cool their heels a little bit more, but even they've come around and really find that there are significant benefits to use in the coy whenever they can. Yeah. So you know, the there are criticisms of robotics that, oh it's just more en enabling technology. Um you know, it's marketing gimmick, you know, there's, there's a cost fa variables. Do you have you seen or do you guys in your practice collect patient reported outcomes? Have you had a chance to look at those or just from a more, more anecdotal standpoint? Uh, what the patients telling you is that influencing your decision to use robotics or, uh, what's the most important variable that, that you would share? I think the most important variable by far is, is what we are seeing, um, during the procedure and with our patients afterwards. Um, I, I mean, I don't even know where to begin. There's so many advantages I think to using handheld robotics like this, you've touched on so many of them. Uh, but you know, the ability to get in there and plan your surgery before you've really done surgery, um, is great because I find that the, the number of times you get halfway through the procedure and you're having to make an adjustment or call an audible, uh, they, they've just plummeted, right. We don't really have to do a whole lot of that anymore because we essentially plan out the surgery and then, you know, hit go, we're burying, uh, the femur and the tibia and the implants go in and, and at the end of the day, the knee feels just like we wanted it to feel. Uh So there are very few surprises now, which is, which is just great. So that's, that's the main driver I think for us using robotics, I mean, there's obviously a lot of other great reasons to use it. Um You know, for me, I, I grew up as a, as a P S surgeon. Um I, I was always a little afraid to dabble with C R uh in large part because I, I was never trained that way and the instrumentation is a little different. The cuts have to be a little different. I was always worried about the PC L footprint um and the ability to use Coy and really just dial in all of those angles, you know, you're supposed to get A and, and then to be able to bur it out uh has allowed me to start implementing C R um in select cases when the PC L looks awesome. And so that's, that's really been great. I mean, it's expanded my uh portfolio as a surgeon, which is always a great thing. So, yeah, excellent points. Um And, and I touched on it briefly as well is that, you know, with the debate about limb alignment, you know, getting a lot of attention over the last uh 10 years or so. Uh Certainly with Doctor Howell's, you know, contributions about having us, we may not all, you know, engage and, and fully, you know, drink the Kinematic kool-aid. But I think to his credit, he really has pushed uh us as a community to think about limb alignment and, and core robotics allows us to do that. And so we see what our preoperative bear survivors deformity is. And if we wanna go neutral and keep us straight neutral access, we can, if we want to do strict kinematics, we can, if we want to do constitutional, like I prefer to do, we can do that as well. So there's really, you know, even in, you know, robotics, you know, probably still to some degree in its infancy. Uh compared to what we'll have five or 10 years from now. I think it's already a tremendous tool that we allows us to uh really advance the surgical decision making. Right. Yeah, it allows you to do whatever you wanna do. Uh You know, I had a great example not that long ago of a patient with a severe August deformity with a, a very bad hypoplastic lateral thermal condal. And using the core was great because, you know, we understood the deformity, we knew what was going on. He ended up needing augments uh on the lateral side, but we were able to use the core to just dial back those resections, you know, to exactly, you know, 5 mm um and you know, the augments just fit perfectly. And so it was, it was great to, you know, even in a complex situation, plan, the surgery out and have everything fit like a glove and balance perfectly at the end of the day. Yeah, and, and the balance is, is key. I think as we would all agree in terms of how the patient perceives the need to feel. Uh And we actually had a, a project that we published last two years ago showing that the incidence of soft tissue releases went down from 46% of cases to about eight percent of cases as we transition from conventional to uh robotic uh total needs. So all hopefully uh uh variables that our colleagues will think about when they make these decisions. So with that, we'll conclude this section and uh move on to uh the last topic for the day.