This is a short (10 minute) video highlighting the conversion from DAA using fluoroscopy to robotic DAA with the Mako 4.0 software program. In less than 20 cases, it is possible to convert to robotic DAA off table and no longer need fluoroscopy for direct anterior hip surgery and maintain the same accuracy for acetabular component placement.
I'm Dr Michael Masini from Trinity Health. Ih A Ann Arbor orthopedic surgery. And today, I'm discussing the learning curve converting fluoroscopic to robotic direct anterior hip Orthoplast. My co authors are as noted on the slide. This is the abstract submitted to this meeting as well. Patient demographics for the patient in this video. These are the preoperative x rays showing advanced degenerative arthritis of the right hip robot assisted th provides an alternative to fluoroscopic guidance, reducing radiation exposure to the entire team. This study was performed to assess the learning curve associated with the adoption of robotic total hip from a surgeon who was previously familiar with the D A approach and used fluoroscopy. A retrospective non randomized study was performed. There were a total of 85 cases performed by a single surgeon. 47 had fluoroscopic manual placement and 38 cases had robotic. The important aspect of the results was that robotic T A was able to position the Aceta component with the same type of precision as fluoroscopic could obtain. After 17 cases, fluoroscopy was no longer needed. And at 15 cases, the learning curve was achieved. This type of software is used to optimize the position of the acetabulum within the native bone. Preoperative planning is very important when doing robotic hip replacement. In this view, you see the green which represents where the cup will be. And the magenta circle where the actual acetabulum is. At first, you're able to adjust the position of the cup in all three planes. I choose as a default 40 degrees of abduction and 20 degrees of an aversion, but I modify the position of the cup accordingly. Once I also plan the femur and interact, the two between virtual range of motion, you can position the various components independently. But the real advantage is that after you've position them, you can then interact them virtually to optimize motion and avoid interp prosthetic impingement. So here we have the Aceta component. I start out with 40 degrees of inclination and 20 degrees of an aversion. And the red dot that you see there shows the first contact that will occur. Thus, you can tell where the patient's native anatomy would be contacted. And also if any inner prosthetic contact would be contacted. Therefore, you can then optimize the position of the socket in the pelvis for every individual patient and then place a checkpoint in the femur as well as in the uh uh a mark of the skin to help with leg length measurement. Before the case begins, I do a direct answer approach with a relative straight incision. Two retractors are placed laterally one along the lateral neck and then a mechanical one more distally on the medial side. Then I place another retractor over the neck and then more proximately. I place a mechanical distractor on the direct head of the rectus. This allows me excellent visualization of the capsule which is then removed in form of a capsulectomy with the bovy. Once we've done that, we place the checkpoint again as noted in market both in the femur as well as distally and the arrays then can be used to measure the optimum depth of the neck cut. Once the neck is cut, then I use a power corkscrew, put it in place and remove the head. One can see the arthritis here on this patient, the retractors are then positioned around the acid tum. I find that a self retaining type of retractor system like this allows the assistance to move away so that I can do the registration process and verification process. This is rather quick with the hip. There are 15 points on the inside of the acetabulum and then 15 points on the outer aspect of the acetabulum, which are used to create the reference system. Again, there is CT scan as the ultimate backup and thus there are checkpoints to verify that this position is indeed correct. Once I've hit these points again, both on the inside of the acetabulum and the outside and verified the position. Then I'm ready to ream I use a single reaming process. And in addition, I actually tilt the table away from me, tilting the table away, gives me direct access to ream. I also lower the table. And thus, even though I use an offset reamer, it significantly improves the ability to ream. In addition, I open up the haptic window from 50 to 10 on the reaming portion, but then narrow it again for placement of the cup. Here in this patient, you can see that we chose 40 degrees and 20 degrees. And after the reaming is completed, the cup is then impacted. I then used two screws. In addition, if you're ever concerned about the position, there are points on the cup you can hit to get the version and inclination to make sure that there are what you think they are and had planned. After this is performed. I then move to the femur. I place a hook under the femur and then I put the table in the trend endured position and lower the legs. I place the opposite leg on a sterile male and we have a bump on the under surface of the table for placement of the operative leg. This lets me achieve the figure of four position with a helo over heel position like one would have with a traction table. It is however, in my opinion, a little more gentle after we've achieved the appropriate position, then a capsular release is performed. The capsule relief involves first initial debulking removal of a portion of capsule. And then when I call a trochanteric peal, I use a, a Bovi and simply inside the capsule directly off the posterior aspect of the tranter proximately. The hook is used really not to apply significant traction but more of a focal point to pull this part of the tranter away from the pelvis. After that's perform, we place the leg in abduction and then start prepping the proximal femur. I place the box oxy tome as turned by my preoperative planning in the robotic system using the porous fossa as the starting point using that and bending toward the center of the neck. I then can recreate approximately at least the version that I've planned the usual type of prep. Then with the broaches is performed followed by calcar reaming and then trialing of the stem. After that, once we get the trials in place, I assess the leg lengths both robotically using checkpoints and arrays. I place one head size smaller than one. I had planned to make it easier to get the hip in and out of the joint. And then I can assess leg lengths range of motion both robotically through the computer but also clinically, which I think is a big advantage with doing the direct an interior approach off table. In this particular case, both the clinical and computer measurements were very close as far as the offset goes. I actually use the offset of the stem in my initial planning, I basically put simply the blue center of the head at the green center of the acid tab and that I think is the correct offset and I don't chase the offset numbers in any way. Once I've completed this portion of the case, then we will then dislocate the hip, placing it back on the hook and remove the trial and put in the final implant, the final implant in place again, I check lag line check range of motion as can be seen in the video. Once again, I believe being off table provides some advantages. As this is the true leg length, the patient will experience as you see the computerized look of the X rays and then here is the wound at closure time realizing again that simply the fascia over the tensor fascia lata is closed and then a capsulectomy was performed otherwise, no soft tissue releases were performed around the hip that need repair. The clinical study again is performed and also submitted for evaluation. These are the post-operative x-rays in conclusion, then direct anterior total hip can be performed with robotic assistance. And without the need for fluoroscopy, you can achieve equal positioning of the acetabulum and the learning curve is approximately 15 cases to have time neutral for your procedure. Thank you.
