Innovations in Robotic Assisted Surgery

Published October 17, 2017

CAO physicians are passionate about providing the highest-quality orthopaedic care. As a result, they’re at the forefront of the latest technology, utilizing innovative new techniques and contributing to scholarly research.

We asked Dr. A. Brion Gardner, a joint replacement and sports medicine specialist in our Prince William Orthopaedics, Hand Surgery & Sports Medicine care center, to share his experience with one of the latest trends – robotic-assisted surgeries. Here’s what he has to say about the greater visualization and precision the technology offers, and the resulting patient demand:

First of all, can you talk us through exactly what it means to undergo robotic assisted surgery?

Patients can have the image that there’s a free standing, human-like robot standing there doing the surgery – but that’s not actually the case. Right now, robotic-assisted surgery involves a machine with a robotic arm that assists the surgeon in making more precise and more accurate placements during hip replacement or knee replacement surgeries. It’s a computer program that has anatomical mapping of the patient, either by a CT scan or MRI. Based on the patient’s own anatomy, the computer can limit the parameters where we place that robotic arm of the instrument we’re using.

I think in the future, the technology will be even more developed. Instead of using freehand surgical saws and knives, everything will go to a robotic-assisted model.  

What robotic-assisted surgeries do you perform?

Right now, I do hip and knee replacement surgeries with the assistance of a robot. I use the robotic assistance in all of my partial knee replacements, and I’m transitioning to total knee replacements using the robot. About half of my total hip replacements use the robotic assistance, mainly for help with placing the artificial cup that helps to form the new hip socket.

Are there situations or patients that aren’t a fit for robotic-assisted surgery?  

In hip replacement surgeries, it’s not always necessary. There are two common approaches to hip replacement surgery. With an anterior approach, the patient is lying on their back and you can use an x-ray during surgery, so you can take pictures to make sure you’re in an ideal zone to position the cup. In a posterior approach, the patient is on their side and it’s not as easy to get an inter-operative x-ray, so you’re looking at visual cues. With the use of the robot, you get computerized feedback on a video screen, which replaces an x-ray machine.

What are the benefits of robotic assisted surgery to the patient?

The number one benefit is greater precision. The robotic assistance ensures that 99.9% of the time, the placement of our implants and components are put in accurately. This is especially important for hip replacement surgery, where the number one reason for a complication such as a dislocation is if the cup is put in an incorrect zone.  You want the cup angled a certain way going front to back and from side to side, and if you are outside of what is called the ‘safe zone,’ then the risk of having a dislocation of the hip is much greater. The precision and accuracy of placing components decreases this complication rate.

What are the benefits to the surgeon? Is it a faster or easier procedure to complete?

As with all new procedures, there’s a learning curve for the surgeon. But after you’ve been trained and performed the first couple of cases, the speed in which you can perform the surgery is similar to if you were not using the robot. Occasionally, it can take a little bit longer because you do have to place antenna, if you will, that communicate with the computer. That can add a little time, but for the most part, this approach takes about the same amount of time. There’s also an advantage to the surgeon and surgical team where with robotic assistance, you don’t need to have as many trays on the scrub tech table in the back because you don’t need to do a lot of measuring. There’s a not a lot of extra instrumentation that you would need, and that significantly decreases the clutter on the back table.

What makes you choose to offer robotic assisted surgery as an option to patients versus traditional surgical options?

My use of the robot for hip surgery is still evolving. I’ll elect to do anterior or posterior hip surgeries based on patients’ desires, their bodies and whether they have had previous surgery. If I’m using the posterior approach, 100% of the time I use the robot. When I’m going anterior, depending again upon the patient’s size, I may not use the robot. I still haven’t made a full commitment to using it 100% of the time.

I think I will get to that point eventually, especially as the technology evolves. I do use it for all of my partial knee replacements. The technology for total knee replacements has just emerged in the last year, and as it gets better I anticipate transitioning for those procedures as well.  

How long have you been offering robotic assisted surgery as an option to your patients?

I was introduced to the technology about six or seven years ago. As it became more popular, naturally I was curious and interested to learn about this new technology that could ultimately benefit my patients. So I went to a training course where I learned how to manipulate the robot and trained on a cadaver.

I was slightly skeptical about using robotic-assistance, and in the back of my mind I was planning to quickly convert to traditional, open techniques for performing the surgery in my first cases. But once I got through the first couple of cases and started seeing patients in follow up, they were ecstatic and I couldn’t really explain the difference in their early post-op satisfaction, which they seem to maintain, except for the addition of using the robot.

So after the first six months of using the robot, the patients were doing very well and spreading the word to their friends, colleagues and family that I offered surgery with the assistance of a robot. New patients started to request it, and it was a no-brainer to continue with that technology.

I think this is the wave of the future in surgery. It’s like any industry – it’s always beneficial to have the assistance of a computer model and machine to improve your accuracy and efficiency. And, robotic-assisted surgery is not just for orthopaedics. Doctors are using it in general surgery, neurology, and gynecology, and I think it will be the standard for the majority of surgeries in the future.

How has robotic assisted surgery changed over the years?

The user-friendliness of it has evolved, and the software has gotten better, faster and more accurate. The instrumentation has also improved, as the robotic arm used to be a lot bulkier and more difficult to maneuver. You had to be pretty strong to position it where you wanted it, but now it is less bulky and has much more fluid movement. The drills attached to the robotic arm have become smoother as well.

Do you expect more advancements in the coming years?

Right now, the majority of robotic assistance in orthopaedics is done in hip and knee replacement surgeries, and I expect it will be extended to shoulder replacement surgery and potentially to fracture care. I know there is also computer assistance with spine surgery now, as they have robotic navigation.

I believe that eventually we’ll have a robotic application for any procedure we’re doing that involves the bones – whether that’s joint replacement, fracture fixation or sports medicine cases like ACL surgery. We need to have precise placement of our instrumentation and exact drilling for all of these procedures, and we don’t yet have a 360 degree visualization of most bones. That hasn’t come online as of yet, but I know that us surgeons would love that, and the companies are pushing their researchers towards developing that as well.

Dr. A. Brion Gardner is a sports medicine and total joint replacement specialist at the Prince William Orthopaedics, Hand Surgery & Sports Medicine care center in Manassas, Virginia. Dr. Gardner has expertise in arthroscopic ankle, knee, shoulder and hip surgeries, fracture care, robotic-assisted surgery and war extremity injuries. Dr. Gardner received the Navy and Marine Corps Commendation Medal for his care of critically wounded Marines and Navy Sailors in Iraq and Afghanistan. He has been a contributor to in the NFL Forum “The League,” writing a weekly analysis of sports injuries, and has also served as a contributor to television and radio sports talk shows as a medical analyst.