By: 1 March 2022
Combining novel technologies is key to achieving advances in orthopaedic surgery

Orthopaedic surgeon Sean D Toomey discusses the value of robotic surgery and how it can be used to elevate the operative room efficiently

As modern medicine evolves, technological advances are changing practice across the treatment landscape and boosting the quality of care for patients. For specialists in interventional orthopaedics, as well as for our colleagues in urology, gynaecologic oncology, urogynaecology and many other fields, robotic surgery stands out as a key exemplar of that progress. As an early adopter of this strategy, I have seen the value it can add in the areas of patient-reported satisfaction and outcomes, as well as orthopaedic surgeon satisfaction, due to the enhanced knowledge and precision execution afforded by the technology, in addition to its ability to elevate operative room efficiency.

But due to the novelty of these systems, hesitancy by some about trying them, and challenges to training due to Covid-19 travel restrictions, robotic technology has not yet saturated orthopaedic practice. For those of us committed to sharing and teaching this strategy, these obstacles raise questions about how best to roll out robotic surgery so that it reaches all surgeons who are interested, allowing them to benefit as quickly as possible.

Perhaps not surprisingly in this time of medical innovation, I have found that applying a separate but synergistic technology significantly increases one’s ability to reach and instruct colleagues who are eager to learn more about robotic surgery and see it demonstrated. Through a live-from-the-operating-room broadcast technology, I’m able to offer education anytime, anywhere about the Mako SmartRoboticsprogram, one of several alternative technologies to become available to orthopaedic surgeons over the past couple of decades. By providing detailed visuals and allowing me to converse with observers as if they were in the room with me, the Avail System vastly increases the number of doctors and medical device representatives I can reach while reducing time spent travelling.

This is promising news for our orthopaedic surgery field as it grows to embrace new strategies capable of improving the precision, efficiency, and efficacy of our surgical engagement, ultimately leading to an enhanced ability to change the lives of our patients for the better.


New technology sparks new advantages 

Practice-changing technological advances in orthopaedics are nothing new; like all medical specialties, the field is built on innovations that were, at one time, revolutionary. A prime example goes back to 1962, when Sir John Charnley introduced “low-frictional torque arthroplasty,” [1] the hip replacement surgery that has been the industry gold standard for more than five decades. His inventions consisted of a thick plastic socket along with a small, polished metal ball designed to replace the head of the thigh bone. Moreover, to support the replacement procedure, he also created a clean-air enclosure to reduce the threat of infection, a specialised instrument tray system to accommodate the necessary tools, and total body exhaust suits to protect both the patient and the surgeons.

Through his Centre for Hip Surgery at Wrightington Hospital in the UK, Dr Charnley not only developed his novel techniques but taught them to specialists, surgeons, and biomechanicians from across the globe. Today, as minimally invasive robotic-assisted surgical systems are introduced across orthopaedics, paving the way for physician uptake is just as important as it was when Dr Charnley set out to spread the word about his hip replacement techniques, as these latest advances will likely further improve our practices.

But unlike when total hip arthroplasty was new, today’s medical environment allows for live streamed communication so that experts can more comprehensively and rapidly communicate details about the latest orthopaedic techniques.

Of the broadcasting systems in use at my facility, I prefer Avail’s A/V hardware and software system, in part because it has a large video monitor that most clearly shows me what my viewers are seeing, so I can make sure I’m facing the right way to facilitate observer visibility. Beyond that, the high-definition video quality and viewer-controlled zoom capability are superb, the system’s operation is streamlined and user-friendly, and the opportunity for two-way communication is key to facilitating dialogue between myself and the viewing audience. It’s very satisfying to be able to offer my viewers “aha” moments, such as insights into extremity and retractor positioning, intraincisional pin placement, proper accommodative leg rotation and positioning, pearls for bone registration and execution of saw cuts or acetabular reaming, or even simply the best exposure tips and tricks to remove bone cement on a partial knee replacement.

In particular, I find the Avail System well-suited for the teaching of robotic surgical techniques. For instance, these include Stryker’s Mako SmartRoboticstechnology, introduced in 2006, which facilitates robotic-assisted knee and hip surgery by allowing doctors to pre-operatively plan patient-specific implant size and placement based on a 3D model of the joint. Then, the surgeon can capture range-of-motion data and adjust implant placement in real time during surgery. And finally, the system features a robotic arm that assists the surgeon in conducting bone preparation and implant placement according to plan. This technology has shown other direct patient benefits such as aiding in the elimination of the need to use intramedullary rods and cutting jigs. It is known that intramedullary rods have been associated with embolism [2] and cutting jigs have been shown to leave behind metal debris [3].

Another robot used in total knee replacement is the VELYS Robotic-Assisted Solution by DePuy Synthes, a Johnson & Johnson company, which was approved in early 2021 and designed for use with the ATTUNE Total Knee System. Other systems include those used for spinal surgeries, such as Zimmer-Biomet’s ROSA ONE Spine and Medtronics’ Mazor X Stealth Edition robotic guidance platform.

Intuitive Surgical’s da Vinci robotic system has been used for some spinal surgeries, [4,5] but its main indications include urology, gynecologic oncology, urogynecology, and general surgery [6,7]. All of these systems are being introduced against a broader backdrop of technological innovation that includes devices such as augmented reality glasses for use during surgery and 3D printing of orthopaedic implants, advances that likewise will require field-wide education so that more precision and personalised treatment can be realised. Although I haven’t tried every robotic-assisted surgical system on the market, I can attest that this type of technology confers a decidedly positive procedural impact, as I’ve been using Mako SmartRoboticssystem since 2009 with great success. The technology has maximised my capabilities in over 3,500 robotic-assisted joint replacement cases so far, and I’ve had the opportunity to teach over 10,000 of my fellow surgeons around the world to use it. Beyond those in the United States, this has included surgeons in India, mainland China, Hong Kong, Japan, Korea, England, Australia, New Zealand, Romania, Germany, Thailand, Malaysia, Singapore, Australia, Ireland, and Scotland, among other countries.

Initially, Mako robotic arm assisted surgery was introduced to assist with partial knee replacements, using 3D imaging to allow a precise operation through a smaller incision with much greater accuracy. Since then, the Mako SmartRoboticsprogramme has expanded to offer total hip and total knee replacement technologies that are potentially more precise than standard techniques and promote better and quicker healing. Among Mako’s key advantages are that it offers data analytics to help with decision-making and assist in guiding surgeons through procedures based on the surgeon’s pre-operative surgical plan. In my experience, this, along with the ability to assess the soft tissue envelope and make modifications to the plan in real time, has resulted in a reduced overall need for soft tissue releases when deformity is less severe in total knees and allows direct feedback for leg lengths and offset for total hips [8].

Notably, these kinds of advances provide an opportunity to improve patient satisfaction with the outcomes of total knee replacement, which has lagged in comparison with other joint-replacement procedures. Promisingly, in a study that compared patient-reported outcomes 6 months after total knee replacement surgery, patients whose procedures were conducted robotically reported less pain and higher satisfaction than those treated with conventional surgery [9]. Furthermore, data collected in a prospective study comparing the early postoperative outcomes of jig-based total knee replacement versus Mako Total Knee surgery showed that the robotic-assisted procedure was associated with a 26% reduction in hospital length of stay and less need for opiate analgesics or inpatient physical therapy sessions [10]. A different study found that the Mako Total Knee was associated with less bone and soft tissue damage [11]. Going forward, we will collect and report on longer-term data, which I’m optimistic will confirm that the use of robotic-assisted technology in hip and knee replacement surgery improves patient outcomes.

One reason I am confident in this is that robotic technology continues to evolve. For instance, the Mako total hip software was just updated to include the influence of the patient’s pelvic tilt and potential for impingement throughout hip range of motion [12]. It is known that pelvic tilt may change as a patient moves from standing to sitting, resulting in a change of acetabular orientation. This is based on each individual’s spinopelvic anatomy. Mako technology is now able to account for this change and reflect this in the patient’s implant placement plan.

Finally, it’s worth noting that robotic surgery offers physical as well as technical advantages to its users. Antonia Chen, MD, an orthopaedic surgeon at Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School, along with her colleagues, has found that robotic-assisted surgery is ergonomically superior [13] to conventional joint replacement when it comes to the level of spinal strain experienced by orthopaedic surgeons. This suggests that the technology can help keep us exactly where we want to be — in the operating room, functioning at full capacity as we work to improve our patients’ quality of life.


The challenges of rollout 

Orthopaedic surgeons are, simply put, some of the most highly trained specialists in medicine. After completing medical school, six years of additional training, and several years in practice, many of us feel so confident in our skills and expertise that we are apt to underestimate, or even flat-out reject, newer technologies as unnecessary to our success. However, it’s important for even those among us with the most exemplary records to realise the possibility that we can offer our patients more precise results and a higher rate of satisfaction by adopting novel techniques such as robotic-assisted surgery. One might recall that, in our not-too-distant past, arthroscopic-assisted meniscal or ACL surgery was considered “new technology” and “innovative.” Now, it is commonplace and expected by our patients.

Unfortunately, rolling out new surgical techniques — even to our colleagues most eager to learn and perform them — can be challenging, and the learning curve can seem intimidating, especially for surgeons who lack experience using computer-assisted navigation in joint replacement surgery.

Complicating the learning process are obstacles that have been preventing orthopedists from traveling to meet with experts who can discuss and demonstrate robotic-assisted surgical techniques. Although in-person collaboration is our gold standard, many orthopaedic surgeons, along with medical device representatives, have faced travel restrictions since the Covid-19 pandemic began in March 2020. Now eager to get back on the road, many nevertheless grapple with concerns about the ever-changing travel restrictions and quarantine requirements, or about safety in light of new virus variants. More evergreen concerns for health systems and device manufacturers focus around the high cost of travel — not only in dollars, but in hours — at a time when virtual collaboration can be a more cost-effective, accessible, and effective alternative.

That is exactly why Stryker’s education platform for adoption of the Mako System includes opportunities for virtual surgical observation. Viewers can securely log onto Avail’s web-based system to observe and converse with experts who are performing Mako robotic arm-assisted surgery on patients in real time. This kind of livestreaming is a highly valuable solution, as it vastly expands the number of surgeons who can watch a procedure. After all, it can be easier for surgeons to take a two-hour break in their day than a two-day break in their work week — or a two-week hiatus to comply with a travel-related quarantine.

As a teacher of robotic technology, I’ve found that being able to livestream from my own OR is a great advantage. While I can certainly visit another facility to lecture about Mako and the latest upgrades to the system’s software, I don’t always have operating privileges on site, and thus am unable to demonstrate on an actual patient. By using Avail to broadcast from my own surgical suite, I can share my demonstrations with colleagues at any facility in the world.


Maximising educational efforts supports technological progress 

The educational landscape was different when I was learning to use Mako SmartRobotics. To pick up these techniques a dozen years ago, I needed to fly to California to meet with system engineers for tutorials and didactic lectures, and then make additional trips to collaborate with proctors for hands-on cadaver work. Prior to the advent of technology such as Avail’s, the other alternative was to attend occasional meetings of national or international peer groups to collaborate on best practices related to robotic-assisted surgical technology.

But now, using this remote collaboration technology, I’m able to virtually offer the same kinds of tutorials and lectures I once attended in person. And since showing is better than telling, I especially appreciate the ability to hold these discussions while conducting live cases that can be observed by anyone, anywhere. Ultimately, this strategy is whittling down the timeframe for spreading this knowledge to orthopedists around the world, and it’s one that I’ve been using regularly. In one recent broadcast, I had the pleasure of simultaneously reaching doctors in a potpourri of countries including Korea, Japan, Romania, Australia, and the U.S. with a live surgery. My surgical team found it thrilling to know that the broadcast from our ambulatory surgical centre in Seattle, Washington, was being shared with people across the globe. It was a fun, powerful, and rewarding thing to do.

As more facilities around the world adopt the Avail System, I look forward to using the technology to virtually proctor cases, a crucial function since surgeons must conduct (cadaveric) procedures under the guidance of an expert before using the Mako technology independently. Those who have the digital collaboration technology will be able to use it to broadcast their cases to me so that I can advise them in real time while clearly visualising their hands, positioning, surgical execution, real-time imaging, and the patient — tasks that are often impossible when teams rely on technology that is not up to the job, such as smartphones, to communicate during these sessions.


Widespread technology uptake benefits all stakeholders 

Ultimately, using virtual collaboration to expedite the rollout of cutting-edge surgical technologies will support the goals of all stakeholders.

From an industry perspective, Avail allows device companies to educate on their technologies more quickly and thoroughly, providing an obvious competitive edge. With this broadcast technology, medical education can be more frequent and effective, with less travel. This strategy is particularly powerful because, as some field representatives have told me, they typically enjoy a better view of a robotic-assisted surgery and associated imaging when watching remotely through the Avail System than if they were standing nearby in the OR.

For doctors who use robotic-assisted surgery and the facilities that employ them, the adoption of the technology confers a certain sense of excellence, allowing practices from small ambulatory surgery centers to large health systems to differentiate themselves from their competitors by touting their own investment in a surgical advance designed to generate better outcomes for patients.



As modern medicine evolves, robotic-assisted surgical technologies are poised to effect significant positive changes in practice, particularly in the orthopaedic arena.

Yet, there are challenges to the adoption of such technologies, including hesitancy on the part of physicians about uptake, learning curves, and limitations on travel for doctors and medical device representatives.

Fortunately, the broadcast of live medical lectures and demonstrations can facilitate the adoption of robotic surgical techniques, as I have found in teaching Mako robotic arm assisted surgery with the support of the Avail System for remote collaboration. These live broadcasts from the operating room allow experts to maximize the spread of knowledge about new technologies to doctors across the globe while reducing the need for travel, ultimately ensuring that these strategies are rolled out as quickly and thoroughly as possible.

This kind of technological pairing has demonstrated benefits for device companies, medical practices, doctors, and their patients. As such, doctors and device companies should consider incorporating live-from-the-OR broadcast technology into their strategies for the rollout of cutting-edge tools across the global orthopedic landscape.


Author: Dr. Toomey is an orthopedic surgeon with Orthopedic Physician Associates (OPA) of Proliance Surgeons in Seattle, Washington, who specializes in robotic-assisted hip and knee replacement surgery. 


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