Smart Devices, Robotics, Sensors: Tools to Improve Patient Outcomes

	Martin Roche, M.D. Holy Cross Hospital

Martin Roche, M.D., is a board-certified orthopaedic surgeon and Director of Robotics and Joint Reconstruction Fellowship at Holy Cross Hospital in Fort Lauderdale, Florida. He was a consultant on initial development for MAKO Surgical’s RIO robot and was instrumental in bringing that technology to market; further, he performed the first Makoplasty robotic-assisted unicompartmental knee procedure in 2006 and the first RIO-assisted total knee arthroplasty in 2012. He is the Founder and Chief Medical Officer of OrthoSensor, which specializes in musculoskeletal sensors, microelectronics and data management.

At OMTEC® 2018, Dr. Roche presented his experience with robotics and sensors. We wanted to learn a little more.
What got you personally hooked on these technologies?

Dr. Roche: As an orthopaedic knee surgeon, I was very frustrated with the percentage of patients who still were dissatisfied with their outcomes, and our inability to meet their expectations. As an educator, we were using instruments developed over 20 years prior, with poor ability to transfer our intra-op knowledge to our peers. We have all been taught that knee arthroplasty is a “soft tissue” procedure, but we lacked the technologies to quantify this critical element.

The key to me was to develop a system that defined our pre-op plan and utilized quantitative data intra-op that allowed a customized approach, and then execute the plan in an efficient, safe manner. I am always evaluating new technologies that have a role in our treatment pathways, and focus on ones that can improve our patients’ outcomes. The current need to define the “value” of these technologies is presently focused on the economics and benefits of any technology. This new paradigm of introducing new technologies into the orthopaedic sector takes a significant investment from technology companies.

How does the use of robotics and sensors—in the O.R. and after the procedure—help the hospital do a better job and improve patient satisfaction?

Dr. Roche: A surgeon needs data to make objective decisions intra-operatively. The subjective Art of Surgery is poorly translatable. We can only compare our outcomes with integrated data extending from pre-op evaluation, through intra-op technique, extending into post-op recovery.

Intra-op sensors improve the surgeon’s ability to achieve soft tissue balance while performing a total knee arthroplasty (TKA). Multiple studies and a randomized, controlled trial have confirmed that a balanced knee improves patient outcomes and satisfaction. This has also translated into fewer post-operative resources utilized, resulting in cost savings for the system.

Robotic-assisted TKA improves a surgeon’s ability to execute the pre-op plan with safety through haptics, with consistent, accurate bony cuts. Patients are experiencing less pain, and improved outcomes scores have been published. These technologies turn surgical instruments into smart tools that provide real-time, actionable data. The utilization of robotic sensor-assisted surgery will become the standard in knee arthroplasty. It will enable surgeons to achieve similar outcomes irrespective of their experience, and customize the procedure to each patient’s pathologic presentation.

In your presentation at OMTEC, you mentioned, “Orthopaedics in my opinion is very behind cardiology, neurology and neuroscience because they are looking at everything implanted, integrated and talking to each other, whether it’s a pancreas or a heart—how you’re thinking and feeling, vs. us who are just putting metal and plastic in.” How far behind do you think we are? Five years? More?

Dr. Roche: We have to understand that the musculoskeletal system is interconnected to our neurological, cardiac, GI and endocrine systems, etc. In other sectors, we are implanting sensorized microelectronics to monitor and now respond and treat pathological processes. The orthopaedic community is slowly focusing on data to improve the patient’s pre-operative status, and implement surgical pathways to standardize treatment. The next step is monitoring outcomes, and there is an early interest on post-op connectivity and wearables.

In the next five years, sensors will be integrated into the devices we implant routinely, to monitor the implant and the patient’s activity. As microelectronics become smaller, require less powering and can transmit data wirelessly, the ability to react to pathological processes like infection, non-unions, implant function and bone health will be achieved. FDA is actively evaluating the clearance pathways for smart devices in orthopaedics.

Knowing where we are today, what do you realistically expect to see next in the use of robotics and sensors? How soon could we have those low-profile haptic exoskeletons on the surgeons’ hands?

Dr. Roche: The progression of tactile electronics, augmented visual reality devices and robotic automated processes will drive this integration in the next five years. We need to incorporate data-driven artificial intelligence to select the patients appropriately, and then customize the procedure to the individual patient with algorithmic machine processing. The surgeon still wants to operate, but if this technology makes the procedure more consistent, efficient and generates improved outcomes, the patients will request it and surgeons will utilize the data to potentially develop the next surgical procedures and personalized implants.

When we “get there,” what does that future mean for the people who build the implants? How will implant design evolve as robotic, sensor-based and computer assistance technologies advance? What kind of skills are they seeking in their new engineers?

Dr. Roche: I have had the good fortune of working with hundreds of engineers over the last 20 years. The evolution from plastic and metal processing has really accelerated in the orthopaedic sector. Teams now consist of biomechanical, biomedical, bioenergy, bioinstrumental, biomaterial, electrical, medical imaging, software and robotic system engineers. The early integration of clinicians, rehabilitation and economic experts is now critical. The future will then extend into bioengineering, in which the bioimplants will be challenging the molecular and genomic aspects of disease in a personalized manner.

The data from all of these processes will revolutionize orthopaedic care into defined pathways, with predictable outcomes. The next-generation technologies may define and regulate a disease process through stem cell and regenerative processes.

Through all this rapid evolution, the clinician must take a leadership role. The successful innovators will focus on bridging the human experience into this technological evolution.