Advances in Orthopedics

Robotic Assistance Supply Management Patient Experience Anesthesia Orthopedics

By: Dan Cook | Editor-in-Chief

Published: 2/7/2022

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Surgery without sedation, the ramping up of robotic-assisted joint replacements and the emergence of smart implants are pushing patient care forward.


If you want to get a glimpse into the potential of outpatient surgery, look no further than orthopedics. Surgeons, armed with the industry’s latest technologies and tools, are rethinking what’s possible to perform in the same-day setting. More joint replacements are moving from inpatient hospitals to ambulatory surgery centers and the increasing popularity of wide-awake hand surgery shows some procedures could shift to office-based procedure rooms. There’s little doubt the future burns bright in one of surgery’s hottest specialties.

Awake and involved

Increasing numbers of patients are undergoing hand procedures without sedation. Two major innovations have fueled the wide-awake surgery movement, according to Donald H. Lalonde, MD, FRCSC, a professor in the division of plastic surgery at Dalhousie University in Nova Scotia, Canada, and one of the leading proponents of the technique.

The first is that using epinephrine as a local anesthetic — it’s a vasoconstrictor that limits bleeding at the surgical site — is safe and eliminates the need for a tourniquet to keep the operative field clear of blood. That means patients no longer require sedation to tolerate the tourniquet, a factor that eliminates anesthesia-related complications.

The second is the concept of tumescent anesthesia, which involves injecting large volumes of low-dose epinephrine into subcutaneous fat to numb a large area of skin. Administering 7 mg/kg of lidocaine with epinephrine is exceedingly safe and does not require vital signs monitoring, according to Dr. Lalonde, who says the local anesthetics are injected under the skin at least 2 cm around where instruments and hardware will be inserted.

Patients who have surgery without sedation don’t undergo extensive pre-op testing, don’t need to fast before procedures and don’t suffer PONV — significant patient-satisfying pluses. “They also receive no medications before or during surgery, so they’re able to leave almost immediately after the procedure is finished,” says Steven Yang, MD, a clinical associate professor in the department of orthopedic surgery who’s been instrumental in bringing wide-awake hand surgery to NYU Langone Health in New York City.

The types of surgeries that could be performed with patients awake are broad, according to Dr. Yang. He restricts application of the technique to small, quickly performed procedures — carpal tunnel releases, trigger finger releases and ganglion cyst excisions — but the technique has also been used for larger, more complex surgeries such as fixes of distal radius and elbow fractures and nerve repairs. “We’re slowly pushing the limit of what’s possible and what patients can tolerate,” says Dr. Yang.

Wide-awake hand surgery also has the potential to significantly improve outcomes. Patients with a trigger finger develop a thickening of the flexor tendon, which glides through a series of small pulley-like structures to control the bending of the finger. If the tendon gets stuck on a pulley, the finger catches each time the patient tries to move it. It’s a painful and potentially debilitating condition. The corrective surgery involves releasing or cutting one of the pulleys at the base of the finger, allowing the tendon to move freely. 

Dr. Yang says there is some anatomic variability in the pulleys, a factor that could require surgeons to dissect more of a pulley or create a release farther along the length of the tendon. “When patients are awake during surgery, surgeons can ask them to move their finger through a full range of motion to confirm the pulley has been fully released before the surgery is concluded,” he says. “That’s a major advantage of wide-awake surgery.”

The technique isn’t suitable for every patient — about 80% of Dr. Yang’s patients opt for it when given the chance — or surgeon, many of whom are accustomed to operating on anesthetized patients and are notorious for sticking with protocols and methods that have been proven over time. They must also talk to awake patients and explain each step of the procedure, which can be unnerving for some. “Even the nicest and most congenial surgeons are not used to social interactions during surgery,” says Dr. Yang. “They view the OR as a quiet place where they can focus solely on performing the operation.”

Robotics could allow surgeons to expand their practice and creates a business opportunity for surgery centers.
— Dr. David Mayman

However, talking with alert patients can prove beneficial. What better way to get them actively involved in their own care and invested in the outcomes of surgery than by having them watch the procedure as it’s being performed and interact with the surgeon who’s performing it?

“I wasn’t fully aware of the power of communicating with patients during surgery,” says Dr. Lalonde. “I’m able to talk to them about their expected recovery and responsibilities for taking ownership in their post-op care plan. The practice has decreased my rate of complications.”

Data-driven results

PRECISION PLANNING Robotic platforms continue to evolve and the technology is expected to play a more prominent role in joint replacements over the coming years.

Robotic-assisted joint replacement surgery continues to entice with the promise of improved outcomes. Orthopedic surgeon David J. Mayman, MD, a joint replacement specialist at the Hospital for Special Surgery in New York City, says computerized navigation and robotics result in more precise and accurate bone cuts and implant placement than what’s possible with the mechanical guides surgeons have used for decades. However, there isn’t a lot of data that shows the technology leads to better joint function — at least not yet.

Dr. Mayman says the big industry players in orthopedics realize robotic hip and knee replacements are a growing trend and have launched user-friendly platforms that work differently but are intended to help surgeons reach the same goal: High-quality outcomes that are the result of optimized soft-tissue balancing in the joint through a full arc of motion.

The first generation of computer navigation and robotic systems were expensive, bulky and took up valuable space in ORs and a great deal of time to set up before cases, which created a lot of naysayers who pushed back against the early adopters of the technology. Dr. Mayman, a strong advocate of robotics, says the latest devices have evolved into user-friendly platforms that help surgeons make more informed decisions before and during surgery.

Robotic assistance with integrated computerized navigation systems works off CT scans of the patient’s joint, providing surgeons with a 3D reconstruction of the unique anatomy. Surgeons can plot out procedures in the virtual space, including where and how they’ll place the implants for optimal results. “Preplanning also helps with supply chain management, which is of particular concern to freestanding ASCs, where a lot of these cases are moving,” says Dr. Mayman. “Surgeons know which size implants and instrumentation they’ll need, so budget-conscious facilities can streamline their inventories.”

Surgical robots guide surgeons as they make cuts and place implants to ensure they remain in the targeted zone determined by the navigation technology. “Working with a tool that provides reproduceable accuracy allows surgeons to be more precise in their pre-op planning,” says Dr. Mayman. “They’re able to spend more time analyzing ligament alignment and soft tissue balancing in the knee and determining how the anatomy of the pelvis and spine will impact hip replacements.”

Surgeons who work with robotics begin to think about surgery from a wider perspective and gain more confidence in carrying out the surgical plan. “Instead of focusing on the individual tasks of the case, they’re thinking about why they’re performing them and how they fit into the overall scheme,” says Dr. Mayman. Is the implant at the correct angle? Is the joint aligned? How much tension should be placed on the ligaments? “Robotics allows them to consider making minor modifications in real time that could lead to better outcomes,” he adds. 

Robotic assistance also gives surgeons more confidence in performing partial knee replacements, a technically challenging procedure that gives even high-volume surgeons pause before recommending it as a treatment option for patients. Dr. Mayman equates a total knee replacement to knocking down an old house and building a new structure, while a partial knee replacement is akin to taking on an extensive renovation. “That’s more difficult to do, because you have to work with and match the current structure of the joint,” he explains. “Robotics makes partial knee replacements a more precise and reproduceable procedure.”

About 10% of knee arthroplasty patients undergo partial replacements, while historic inclusion criteria indicate 15% of patients are candidates — and some experts believe 20% to 30% of patients could qualify for the procedure. Dr. Mayman says robotics could lead to more surgeons performing partial replacements, particularly sports medicine physicians who treat early arthritic joints but don’t have extensive experience in performing knee arthroplasty. “Many of these surgeons are active in ambulatory surgery centers,” says Dr. Mayman. “Robotics could allow them to expand their practice, which creates a business opportunity for the centers.”

Every big player in the orthopedic space has an FDA approved robot in use throughout the country, so the number of robot-enabled joint replacement procedures is increasing. “There will be significant advances in what the technology allows surgeons to do over the next five years,” says Dr. Mayman.

The increased use of robotics will allow for a deep dive into outcomes, according to Dr. Mayman. “Surgeons will capture data from a very precise tool and see how minor modifications made to surgical techniques impact how well patients do,” he says. “That large feedback loop will eventually help surgeons determine how to best treat individual patients.”

The collection of data aimed at improved outcomes could also receive a boost from the emergence of implants embedded with smart sensors located in the small stem of the tibial component. The sensors capture kinematic data — joint range of motion, step count, stride length, distance traveled and average walking speed — as patients go about their daily routines after surgery. The information is sent to a cloud-based dashboard, which surgeons can access to monitor the post-op function of the patient’s knee and track the progress of their rehab and recovery.

How accurate will the information captured by smart implants be and how much will surgeons and patients benefit from it? That remains to be seen. “The data is currently very limited, but the capability of the technology is immense,” says Dr. Mayman. “In the future, will smart implants detect early infections or wear and tear and loosening of implants? It’s a brand-new application that carries a lot of potential, so we’ll have to see where it goes.”

The same can be said for the field of orthopedics. Surgeons and facility leaders should monitor the latest developments in the innovative specialty that continues to show what’s next in ambulatory surgery. OSM

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