COMPUTER ASSISTED ROBOTIC TOTAL KNEE ARTHROPLASTY

COMPUTER ASSISTED ROBOTIC TOTAL KNEE ARTHROPLASTY TOD NORTHRUP, DO MEDICAL DIRECTOR Florida Sports Medicine Institute St Augustine and Jacksonville, FL Flagler and Baptist South Hospitals

2013 DISCLOSURES No financial interests to disclose Special Thank You to Albert Koenig, MD for great amount of information for this presentation Real Disclosure Always trying to improve my surgical techniques so that my patients can have the best results! TN

Computers Have Invaded Our Lives 2013 FLORIDA SPORTS MEDICINE INSTITUE

Why Computers and Orthopedics Simply we use CAS to improve the Surgeon s perception of the operative field and the surgery that he or she carries out CAS with Robotics has emerged as one of the most important new technologies in Orthopedic Surgery today Orthopedic Surgeon s Best Friend (BFF)

Computers and the Quest for the Perfect TKR Began studying CAOS in the late 1990 s. Early Passive Navigation Systems for TKR GPS for the Knee, finicky and difficult to use, clinically not ready 2nd Generation CAS (Navigation with Integrated Robotics) PiGalileo Plus Orthopedics 2004, Switzerland. 3rd Generation CAS/VPR (Virtual Planning with Robotics) Apex Robotic Technology (A.R.T.) Omni LS & Praxim; USA, France 3D Imageless Bone Morphing with Virtual Planning

Keys to Success in TKA Neutral Alignment Ligament Balancing Implant Fixation Appropriate Sizing Good ROM Longevity of Implants

Goals of Praxim s ART Virtual Robotic-TKR Maximize Accuracy and Consistency of results Customize the Procedure for every patient Minimize the Invasiveness Reduce the number of early TKR failures 2 to Malalignment and Instability of the components leading to early fixation failures and loosening.

Preventable Failures Sharkey et.al. Insall Award Paper 2002 212 Revisions in 203 patients 56% of Revisions done within 2 yrs of index TKA Reasons for the Early Failures: Fixation failure (17%) Instability (21%) Malalignment (12%) 50% Preventable CORR Nov. 2002 2013 FLORIDA SPORTS MEDICNE INSTITUTE

The Literature is Clear Limb alignment is crucial for TKR Mechanical Axis within 3 of neutral CAS-TKR is more Accurate than Conventional TKR CAS-TKR is also more Accurate than CCB-TKR or PSG s* *Accuracy of CT-Based Patient Specific Total Knee Arthroplasty Instruments ~ Francis B. Gonzales, MD, C. Anderson Engh, Jr., MD, Deborah Ammeen, BS, Robert Hopper, PhD AAHKS 2010 Poster Presentation.

CONVENTIONAL TKA

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CONVENTIONAL TKA

CONVENTIONAL TKA FFFFLO

CONVENTIONAL TKA FILL THE IMPERFECT CUTS IN WITH CEMENT!!!

CAS-TKR Frustrating Early Passive Navigation Early CAS-TKR Navigation was performed manually. Surgeon had to physically move cutting blocks by hand in 3 dimensions at once; in the hopes of making 1 mm or 1 corrections. Difficult at best. As you moved block in one plane the cutting block often moved in two other planes. SFI & increased time. Frustrating Fiddle Factor.

Navigation without Automation (Is like Driving a Porsche with a Foot Pedal Engine!) VPR-TKR CAS-TKR

ART-TKR What is Passive Robotics? An automated device that very accurately helps or assists to perform a task but does not do the task on its own. Examples: PiGalileo Mako (partial knee replacement) A.R.T.

Omnilife Science & Praxim The ART of TKR Excellent APEX TKR High Flex technology CAS 3-D Bone Morphing & Virtual Robotic Surgery Allows for Imageless Custom Implantation of every APEX TKR Sizing Alignment Position

Omni Praxim ART Apex Robotic Technology Accurate & Robust Imageless 3D model of the Pt s anatomy Intuitive and Fast Acquisitions (Simple screens & workflow) No change in preferred Surgical approach Virtual Femoral and Tibial Surgery (prior to any bone cuts) Easily Navigable with Passive Robotics and Nano Tech. (No Fiddle Factor & High SFI) Quick Accurate Real Time Validations Consistent Excellent Results Will help to make you a better and more accurate surgeon!

Normal TKR Exposure Depending on Morphology

ART of TKR iblock Surgical Workflow TRACKING REGISTRATION NAVIGATION and CUTS VALIDATION

Tracking Applying Arrays

Monitor Positioning

Registration / Acquisitions Hip Center Kinematic Approach

Registration / Acquisitions

Femoral Acquisitions

Femoral Acquisitions Bone Morphing Validation Checks for Accuracy of 3D Model Will not let you proceed until you have an accurate robust model of patient s knee

Tibial Acquisitions

Pre-Resection ROM and Kinematics

Virtual Femoral Surgery

Conventional Referencing when in-between sizes Anterior Referencing Larger Size Smaller Size Posterior Referencing

ART Referencing A.R.T. Referencing Perfect Size & Fit

Comparison Virtual Femoral Cuts vs. Actual iblock Cuts

Virtual Planning Press Fit Adjustment

Virtual Femoral Surgery

Adjusting iblock

iblock Calibration

Surgery with the Omni Praxim i-block

Active Automated Robotic Navigation

Active Automated Navigation

Femoral iblock Validation

Active Navigation Recutting the Femur Select Positive Recut (or negative) Select once for each mm. Step on Blue Pedal to Activate and Set iblock

Virtual Tibial Surgery

The NanoBlock

Tibial Validation

CAS Alignment Data

ART of TKR Final Implants

ART of TKR Cases

6 Weeks Post Op 78 y/o male: one PT visit

Six wks post-op: one PT visit

ART of TKR Cases S/P HTO

ART of TKR Cases S/P ACL

ART of TKR Cases

iblock Clinical Study Koenig & Plaskos CAOS / ISTA 2011 Retrospective review of first 107 cases June 2010 Jan 2011 Study Outcomes: Accuracy & Efficiency Final leg alignment, standing long-leg x-rays Bone-cut precision (planned vs. measured cuts) Tourniquet time iblock use time Statistical analysis of the learning curve Group 1: cases 1-25 Group 2: cases 26-50 Group 3: cases 51-75 Group 4: cases 76-100 Baseline Factors Group 1 2 3 4 p-value* BMI mean 30.8 32.2 32.9 29.8 0.24 Age mean 66.1 72 71.2 68.8 0.14 Gender (M:F) 11:14 10:13 8:15 11:14 0.9 Deformity mean (max) 6(20) 4.2(12) 6.0(12) 4.8(13) 0.46 *Oneway ANOVA with bonferroni adjustment 2012 ORTHOPEDIC EXCELLENCE OF LONG ISLAND

Results: Femoral and Tibial Component Alignment Femoral Component Alignment ( ) Tibial Component Alignment ( ) 99% (76/77) within ±3 99% (76/77) within ±3 92% (71/77) within ±2 94% (72/77) within ±2 No significant effect of the learning curve on accuracy 2012 ORTHOPEDIC EXCELLENCE OF LONG ISLAND

Omni Praxim vs. Custom Cutting Blocks (Patient Specific Guides)

Custom Cutting Blocks or Patient Specific Guides AAHKS 2010 Poster Presentation. Accuracy of CT-Based Patient Specific Total Knee Arthroplasty Instruments ~Francis B. Gonzales, MD, C. Anderson Engh, Jr., MD, Deborah Ammeen, BS, Robert Hopper, PhD Measured radiographic anatomic alignment and full limb mechanical alignment (50 cases / 40 follow up) The mechanical axis was within 3 of zero for 63% of cases. Conclusion Leg alignment is similar to that obtained with traditional instruments but not as good as imageless computer assisted total knee arthroplasty.

CT / MRI Custom Cutting Blocks Increased Cost of Blocks, Scans, FTE s, Cancelations Radiation Burden Increased Time for Authorizations, time lost going for study, Pre-op planning, Shipping & Check in No Real Time Validation Takes the Computer out of the OR where you need it most. (like leaving your car s GPS at home) Not Proven & Not as Accurate as CAS (2010 AAKHS Poster Engh.) MRI @ $1000/scan x 1,000,000 patients = $ 1 BILLION CCB @ $1500/case x 1,000,000 patients = $1.5 BILLION (and that s only 20% market intrusion by 2015.) Who s paying? Hospitals? MD s? Patients? Industry?

Omni Praxim iblock Low Cost Extremely Accurate Validated Imageless Custom Implantation of every case for sizing, alignment and position. Virtual Robotic Surgery Cut through large Slots, not 4 or 5 in 1 cutting blocks. No Added Cost to the Health Care System. No Radiation No loss of time ( average time 49 minutes / case) Consistent Excellent Results case after case

CCB / PSG Takes the Computer out of the OR where you need it most. (like leaving your car s GPS at home)

VALUE = Product vs. Cost

The Bottom Line Omni Praxim s ibot Makes me a better and more accurate surgeon affording my patients their best potential TKR outcomes and that s what it s really all about. FFFFF

THANK YOU!!