How may robotics, navigation and mixed reality impact the future of shoulder surgery?
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Increased role for robotics, mixed reality
During the past several years, the role of 3D planning has increased significantly in shoulder surgery.
A crucial, and often overlooked, part of this process is the quality of the segmentation that is performed to create the operative plan. At first, surgeons were happy to simply have a 3D plan. However, in 2024, the quality of the plan the software produces is emerging as an important issue. Research has demonstrated that the quality of the segmentation can vary significantly based on the technique that is employed and whether each plan is reviewed by an engineer to ensure the highest quality. A plan that accurately represents the true anatomy of a patient is the foundation on which all the intraoperative technologies are dependent.
One of the most common reasons that we see for shoulder arthroplasty failure is component malposition, particularly on the humeral side. This has been underappreciated as a reason for failure. In a recent multicenter study of 300 consecutive revision shoulder arthroplasties, humeral component malposition was present in 60% of cases and glenoid component malposition in 50% of cases. Therefore, a critical part of any intraoperative technology in the future will be the ability to execute on the humeral side as well as the glenoid side of the joint.
The next step regarding using these technologies will be correlating the position of the implants to outcomes. Remote patient monitoring and collecting this data in a seamless manner that does not require a return to the office will be increasingly important. These postoperative data will allow us to better determine the optimal component size and position of implants for an individual patient.
Emerging technologies, such as robotics and mixed reality, will play an increasing role in shoulder surgery to more accurately and reproducibly execute on the humeral, as well as the glenoid side, when adopting these 3D surgical plans. Accurate longitudinal follow-up data will be essential for success.
John W. Sperling, MD, MBA, is a professor of orthopedic surgery at the Mayo Clinic in Rochester, Minnesota.
Improved surgical precision, accuracy
The unifying theme that links robotics, navigation and mixed reality is preoperative planning. All three of these digital enabling technologies require a surgeon to utilize preoperative planning software to construct a surgical plan, with the selection of implant sizes and precise implant positions. The enabling technologies above then allow for the intraoperative execution of the plan, with the purported advantages of improved patient outcomes, better survivability and fewer complications.
Presently, it is this author’s experience that many revisions are conducted within 5 years of the index joint replacement, with the primary cause of revision being an identifiable and preventable technical issue. Technical issues with anatomic total shoulder arthroplasty that may lead to an increased risk of complications, and possible revision include over-stuffing of the joint, placement of a glenoid component in excessive retroversion or superior inclination and excessive glenoid reaming. Similar technical issues with reverse shoulder arthroplasty include poor position of the humeral component, excessive superior inclination of the baseplate and incomplete baseplate seating. These technical issues may contribute to instability, impingement or notching with polyethylene wear. All the above technical issues can be partially or completely solved by enabling technologies that allow for precise and accurate execution of a preoperative plan.
The literature has demonstrated superior patient outcomes with robotic-assisted partial knee replacement as compared to manual. In addition, cadaveric and sawbones studies have demonstrated improved accuracy and precision regarding glenoid implant positioning. Presently, robotics are being used for soft tissue surgeries around the shoulder, such as tendon transfers and brachial plexus procedures. The advantages of robotic-assisted surgery are generally related to increased precision and accuracy of implant positioning, while the disadvantages include the cost, increased surgical time and the larger OR footprint.
Optical navigation in shoulder surgery, overall, has had better commercial penetration. Studies have similarly shown better objective implant positional outcomes; however, as of yet, these results have not been correlated to improved patient outcomes. Similar advantages and disadvantages exist for navigation as for robotics.
Mixed reality navigation is relatively new in its applications in shoulder surgery. The technology uses digital holograms registered to the patient’s anatomy to guide surgical instruments and implants. This technology has limited clinical outcomes literature; however, cadaveric and sawbones studies have demonstrated improved accuracy and precision.
Presently, all three techniques substantially improve surgical precision and accuracy. However, it is difficult to predict which technique will be superior in the long term. Overall, this author believes that all three technologies will continue to advance and increase market penetrance and, eventually, each will have its own specific indications and ideal markets. The future is bright in shoulder surgery.
- References:
- Batailler C, et al. Knee Surg Sports Traumatol Arthrosc. 2021;doi:10.1007/s00167-020-06283-z.
- Cavanagh J, et al. JSES Int. 2021;doi:10.1016/j.jseint.2021.05.009.
- Fleet CT, et al. J Shoulder Elbow Surg. 2024;doi:10.1016/j.jse.2024.04.030.
- Sanchez-Sotelo J, et al. J Shoulder Elbow Surg. 2024;doi:10.1016/j.jse.2023.09.027.
- Smith CD, et al. Ann Robot Autom. 2020;doi:10.17352/ara.000007.
- Velasquez GA, et al. JBJS Rev. 2023;doi:10.2106/JBJS.RVW.23.00038.
George S. Athwal, MD, FRCSC, is a professor of surgery at the University of Western Ontario in London, Ontario, Canada.
Determine the best plan
The field of AI and advanced surgical technology in the OR is growing, providing numerous new options for shoulder surgery. The integration of navigation, robotics and mixed reality will significantly impact surgeons, hospitals and patients both clinically and economically.
Historically, advanced technologies in orthopedics, particularly in arthroplasty, have struggled with adoption due to the high capital investments required by hospitals. Many companies are now shifting away from selling these solutions as capital investments because of the tight economic constraints in U.S. health care systems. This trend is already prevalent in most countries and hospitals outside the U.S. As hospitals scrutinize additional capital investments without guaranteed return on investment, the sale of equipment has shifted to “placements” and joint-volume agreements. This can negatively impact surgeons and physician-owned ASCs by forcing the use of specific products or imposing fees for not meeting contract minimums. As these technologies grow in the market, it is crucial to consider the financial implications for hospital systems and surgeons.
The primary goal of many advanced surgical technologies is to enable more seamless execution of preoperative plans. While patient-specific instrumentation is available, its high “bail” rate and lack of plan execution confirmation pose challenges. Navigation and robotics, using trackers, cameras and smart instruments guide precise resections and implant placements, reducing complications and revisions, as supported by recent studies from the Journal of Shoulder and Elbow Surgery. Mixed reality technologies have recently plateaued in adoption due to the lack of comfortable/easily implementable hardware solutions and the reliance on third-party technology goggles to advance.
The real breakthrough lies in determining the best plan for each patient. Currently, studies show significant variability among surgeons in planning cases, even for the same patient. By leveraging clinical databases and machine learning, surgeons will soon be able to identify the best treatment options specific to each patient, including implant type and location, to be aided by image-guiding technologies.
Whether through navigation, robotics or mixed reality, smart instruments and tools currently help surgeons place implants more accurately according to their plans. As we collect more data and utilize clinical databases and machine learning, these tools will offer even more intraoperative guidance, including joint tensioning and patient-specific recommendations. This will eventually guide surgeons to choose and execute the implant and a plan that yields the best results for each patient.
- References:
- Hernandez D, et al. Orthop Surg. 2017;doi:10.1111/os.12323.
- Jones RB, et al. Semin Arthroplasty. 2020;doi:10.1053/j.sart.2020.05.004.
- Parsons M, et al. J Shoulder Elbow Surg. 2020;doi:10.1016/j.jse.2020.04.010.
- Youderian AR, et al. J Shoulder Elbow Surg. 2023;doi:10.1016/j.jse.2023.05.021.
Howard D. Routman, DO, is the director of the Palm Beach Shoulder Service at Atlantis Orthopedics in Palm Beach, Florida.
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