Australia’s first robotic help in a hip replacement operation

The surgeon and the robotic arm will work together on a hip replacement.

The surgeon and the robotic arm will work together on a hip replacement. Stryker, Author provided

Ross Crawford, Queensland University of Technology; Anjali Jaiprakash, Queensland University of Technology, and Jonathan Roberts, Queensland University of Technology

The first robotically assisted hip replacement operation in Australia is due to be performed today on a patient in Brisbane.

A total hip replacement (THR) is one of the most successful operations that surgeons perform, with more than 43,000 carried out last year in Australia alone.

The robot technology to help in such operations has been used for some years in the US but has only recently reached Australia.

But if the operations are so popular and successful, why let a robot in on the surgery?

The hip opp

A hip replacement involves an incision to expose the hip joint and the placement of an acetabular component (the cup) and a femoral component (the stem). A head is then placed on the stem and a ball and socket joint is created that is the patient’s new hip.

A typical ball and socket artificial hip replacement.
Ross Crawford, Author provided

Though very successful, the operation can be quite challenging to perform in certain patients such as the very overweight and those with complex deformities due to childhood diseases or trauma. There is also a learning process for the surgeon in performing a hip replacement and it is hoped this can be shortened by using robotic technology.

Accurate positioning of the components of a hip replacement is important. Having the cup and stem in the correct position can decrease the chance of complications such as dislocation, where the head comes out of the cup. Making sure the joint stem is located in a way to ensure optimal leg length may also lead to improved function of the new hip.

Currently, surgeons rely on their experience and judgement to correctly place the components of a hip replacement. Many studies have shown that even experienced surgeons can have difficulty in reliably and accurately placing the cup in the correct orientation. They sometimes find placement of the stem challenging too.

This is where a robot can help.

The robot surgeon

Up until now, the Australian experience of robotic orthopaedic surgery has been limited to partial knee replacements. The first was carried out in April last year, and since then more than 280 of these procedures have been performed.

The first robotically assisted total hip replacement operation will take place today at Brisbane’s Holy Spirit Northside Hospital, and it’s likely such procedures will quickly become just as popular as the knee operations.

The Stryker Mako advanced robotic arm that helps with the surgery.
Stryker, Author provided

So what is different with a robotic total hip replacement and where does the robot help?

The MAKO robotic system is a carefully controlled robotic arm that aids surgeons in placement of the components of a total hip replacement. It makes the operation more accurate and safer for surgeons, regardless of their experience.

The main difference from a patient’s point of view is that a pre-operative CT scan is needed to plan the procedure. Traditionally, surgeon relied purely on an X-ray to plan a total hip replacement.

When performed by a robot, planning for the procedure is done by specialist engineers in collaboration with the surgeon. The engineer and surgeon work together to determine the optimal position for the components and they create a plan.

The plan places the cup in the correct orientation to match the patient’s anatomy and the stem is also sized to fit the patient’s femur. The aim is to accurately restore the patient’s hip anatomy, particularly leg length.

Once the surgery begins, the surgeon exposes the hip joint in the usual way. Trackers are placed on the pelvis and on the femur allowing the robot to register these bones.

The trackers are attached to the bones using small posts with a screw thread on the tip. A series of points on the patient’s pelvis and femur are then registered and the robot creates a 3D representation that matches the CT scan.

Once the robot understands the geometry, it is able to follow any movement of the patient by the signal transmitted by the trackers fixed to the bones.

A cutting tool called reamer – somewhat like a powered round cheese grater – is attached to the robot and is used to prepare the bone to accept the cup. The surgeon holds the reamer but the robot constrains it and will not let the surgeon remove bone beyond the planned amount.

This will prevent any accidental damage to the bone and make sure the reaming can only occur as planned. Human error is removed from the preparation.

After reaming is finished, the cup is grasped by the robot and the robot sets the correct positioning. The surgeon then hammers the cup into the correct position in the pelvis.

They are able to monitor the position of the implant on the computer screen as it is “seated”. The cup cannot be driven in too far, as the robot constrains where the cup can be placed, as with the reamer.

Next the surgeon places a broach in the femur to prepare a cavity for the femoral component (stem). The broach can be tracked by the robot to make sure it is placed in the correct orientation and the patient’s legs are at the planned length.

Once happy, the surgeon cements the stem into where the broach was positioned, places a head on the femur and puts the head into the cup.

Who’s in charge?

Though the robot is constraining the surgeon to execute the plan, the surgeon remains in charge at all times. The surgeon continues to carry all responsibility for the success of the operation and any complications.

This first step of robotically assisted total hip replacement is relatively easy. The robotic technology (robotics, navigation and haptics) being used is very mature.

But as we are seeing in many industries, the capability of robotics is expanding rapidly. It will not be long before the technology is advanced enough to take over far more of the operation from the human surgeon.

Then the big ethical questions will arise. Even now orthopaedic robots are being limited in what they can do because the step to autonomous surgery is currently a step too far.

Like driverless cars, the questions of liability and trust continue to be aired when discussing robotic-surgery or health care.

But also like driverless cars, robotic surgeons do not have to be perfect. They just have to be better than humans.

The Conversation

Ross Crawford, Professor of Orthopaedic Research, Queensland University of Technology; Anjali Jaiprakash, Post-Doctoral Research Fellow, Medical Robotics, Queensland University of Technology, and Jonathan Roberts, Professor in Robotics, Queensland University of Technology

This article was originally published on The Conversation. Read the original article.

Robots in health care could lead to a doctorless hospital

Would you trust your child’s health to a robot surgeon? Shutterstock/magicinfoto

Anjali Jaiprakash, Queensland University of Technology; Jonathan Roberts, Queensland University of Technology, and Ross Crawford, Queensland University of Technology

Imagine your child requires a life-saving operation. You enter the hospital and are confronted with a stark choice.

Do you take the traditional path with human medical staff, including doctors and nurses, where long-term trials have shown a 90% chance that they will save your child’s life?

Or do you choose the robotic track, in the factory-like wing of the hospital, tended to by technical specialists and an array of robots, but where similar long-term trials have shown that your child has a 95% chance of survival?

Most rational people would opt for the course of action that is more likely to save their child. But are we really ready to let machines take over from a human in delivering patient care?

Of course, machines will not always get it right. But like autopilots in aircraft, and the driverless cars that are just around the corner, medical robots do not need to be perfect, they just have to be better than humans.

So how long before robots are shown to perform better than humans at surgery and other patient care? It may be sooner, or it may be later, but it will happen one day.

But what does this mean for our hospitals? Are the new hospitals being built now ready for a robotic future? Are we planning for large-scale role changes for the humans in our future robotic factory-like hospitals?

Our future hospitals

Hospitals globally have been slow to adopt robotics and artificial intelligence into patient care, although both have been widely used and tested in other industries.

Medicine has traditionally been slow to change, as safety is at its core. Financial pressures will inevitably force industry and governments to recognise that when robots can do something better and for the same price as humans, the robot way will be the only way.

What some hospitals have done in the past 10 years is recognise the potential to be more factory-like, and hence more efficient. The term “focused factories” has been used to describe some of these new hospitals that specialise in a few key procedures and that organise the workflow in a more streamlined and industrial way.

They have even tried “lean processing” methods borrowed from the car manufacturing industry. One idea is to free up the humans in hospitals so that they can carry out more complex cases.

Some people are nervous about turning hospitals into factories. There are fears that “lean” means cutting money and hence employment. But if the motivation for going lean is to do more with the same, then it is likely that employment will change rather than reduce.

Medicine has long been segmented into many specialised fields but the doctor has been expected to travel with the patient through the full treatment pathway.

A surgeon, for example, is expected to be compassionate, and good at many tasks, such as diagnosing, interpreting tests, such as X-rays and MRIs, performing a procedure and post-operative care.

As in numerous other industries, new technology will be one of the drivers that will change this traditional method of delivery. We can see that one day, each of the stages of care through the hospital could be largely achieved by a computer, machine or robot.

Some senior doctors are already seeing a change and they are worried about the de-humanising of medicine but this is a change for the better.

Safety first but some AI already here

Our future robot-factory hospital example is the end game, but many of its components already exist. We are simply waiting for them to be tested enough to satisfy us all that they can be used safely.

There are programs to make diagnoses based on a series of questions, and algorithms inform many treatments used now by doctors.

Surgeons are already using robots in the operating theatre to assist with surgery. Currently, the surgeon remains in control with the machine being more of a slave than a master. As the machines improve, it will be possible for a trained technician to oversee the surgery and ultimately for the robot to be fully in charge.

Hospitals will be very different places in 20 years. Beds will be able to move autonomously transporting patients from the emergency room to the operating theatre, via X-ray if needed.

Triage will be done with the assistance of an AI device. Many decisions on treatment will be made with the assistance of, or by, intelligent machines.

Your medical information, including medications, will be read from a chip under your skin or in your phone. No more waiting for medical records or chasing information when an unconscious patient presents to the emergency room.

Robots will be able to dispense medication safely and rehabilitation will be robotically assisted. Only our imaginations can limit how health care will be delivered.

Who is responsible when things go wrong?

The hospital of the future may not require many doctors, but the numbers employed are unlikely to change at first.

Doctors in the near future are going to need many different skills than the doctors of today. An understanding of technology will be imperative. They will need to learn programming and computer skills well before the start of medical school. Programming will become the fourth literacy along with reading, writing (which may vanish) and arithmetic.

But who will people sue if something goes wrong? This is, sadly, one of the first questions many people ask.

Robots will be performing tasks and many of the diagnoses will be made by a machine, but at least in the near future there will be a human involved in the decision-making process.

Insurance costs and litigation will hopefully reduce as machines perform procedures more precisely and with fewer complications. But who do you sue if your medical treatment goes tragically wrong and no human has touched you? That’s a question that still needs to be answered.

So too is the question of whether people will really trust a machine to make a diagnosis, give out tablets or do an operation?

Perhaps we have to accept that humans are far from perfect and mistakes are inevitable in health care, just as they are when we put humans behind the wheel of a car. So if driverless cars are going to reduce traffic accidents and congestion then maybe doctorless hospitals will one day save more lives and reduce the cost of health care?

The Conversation

Anjali Jaiprakash, Post-Doctoral Research Fellow, Medical Robotics, Queensland University of Technology; Jonathan Roberts, Professor in Robotics, Queensland University of Technology, and Ross Crawford, Professor of Orthopaedic Research, Queensland University of Technology

This article was originally published on The Conversation. Read the original article.