Dr. Mike (Host): Welcome to Meaningful Medicine, a Novant Health podcast. I'm your host, Dr. Mike. And with me is Dr. Calvin "Max" McCabe from Novant Health. And today, we explore the rising trend of robotic-assisted orthopedic surgery. Dr. McCabe, welcome to the show.

Max McCabe, MD: Thank you. It's good to be here.

Host: So, more and more people are hearing about robots in the OR. Can you give us just a few examples of the types of surgeries robotics is being applied?

Max McCabe, MD: Yeah, absolutely. It really is revolutionizing things. In my practice in the last 11, 12 years, it's really gone from kind of a narrow application to really changing a lot of what we do. Even broader than that though, if you think about the full spectrum of surgery, it's become the gold standard. For instance, in Urology, with prostate cancer, the lower complications, fast recovery, and really throughout general surgery as well, just improving things. And in my world specifically though, we're seeing huge benefits from it with the robotic knee replacement.

Host: Nice. I started medical school many years before you did, I'll be honest with you. And we didn't even talk about robots at all. So, this is amazing to me. So, lay out for us just the main advantages of robot-assisted versus traditional surgery.

Max McCabe, MD: Yeah. Well, the common thread you'll see, whether you're talking about Orthopedics and knee replacement or General Surgery has improved reliability in terms of consistency, lower complications, faster recovery. And that's been shown again in the broader literature. But in the knee replacement world, we're seeing the first data to come out showed more consistent results in terms of better x-rays, better alignment. But as more and more data's coming out, we're also starting to see more meaningful positive news, which is much better patient satisfaction because we're seeing a little bit faster recovery, a little bit more natural feeling, which is the whole goal of all this is to restore hopefully the function that we had before arthritis developed. And so, I think, it's an evolving field and it's an exciting field, but we're definitely starting to see data to back up exactly what we're doing this for, which is that improvement in terms of customization, patient-specific and turning into improved outcomes.

Host: Yeah, I want to talk a little bit about the improved outcomes, because I think from a patient standpoint, for them, that's the main point, right? Getting back to my normal life as fast as I can. But with that said, help us to understand this a little bit more, because I think when people hear about robots in the OR, they're thinking of androids walking around. Tell us a little bit of what's really happening, what's your role, who's really doing the procedure?

Max McCabe, MD: Yeah, absolutely. The robot really doesn't look like Star Trek. It looks like a highly precision set of measurement instruments and precise instruments to achieve the plan that we've come up with. So, it's still your surgeon doing the operation. But what we do is we start with information. And we typically get a CT scan even before the surgery. So, we have a virtual plan. We've plan out what would look right on a static CT model of a knee in this case. But then, in the operating room, before we start doing anything, we can evaluate, "Okay, this ligament's a little tight. This is a little loose. The knee doesn't come as straight as we want, but we have good flexion." And so, we can adjust that virtual plan to actually suit an individual, a real life person.

And so, it starts with information, and then we are able to accurately execute the plan we come up with. So, it's really better measurement, better customization, which the whole goal is hopefully a more natural-feeling knee replacement, better function, and maybe even earlier recovery. And that's what we're seeing.

Host: So, where are we at with that with pain? Because, you know, most patients, again, I think one of the things that holds them back from doing hip, knee replacements, it's the idea of not being able to move so well for a while, it's the pain, it's that kind of stuff, right? So, where are we at in terms of those kind of improvements in a robotic surgery?

Max McCabe, MD: Yeah. Well, it's still very true. You want to have a good relationship with your doctor. You want to make sure you've tried all the simple, less invasive things. And then, we don't make these decisions based on what the x-ray shows or some outside measure. What really matters if someone's thinking about having something like a knee replacement or a hip replacement is quality life and how they're functioning, doing the things they want to do. Are they getting through their day with a smile or are they limping all the time? And are they able to sleep at night? Because arthritis can be difficult if you can't sleep. It's hard to feel good and productive during the day.

So, first of all, we start with the basics. You always make sure that you have done all the simple things before you'd even consider surgery. And then, you have to honestly evaluate, "Okay, how's this affecting my quality life? How's this affecting my family life, my exercise?" All the things that are important to a well-rounded life. And then, when it comes time to surgery, you definitely want to have a good personalized conversation with your surgeon. What specific things are we going to have to work to get back to? What's the timeframe on that? And we're doing a lot of work with trying to improve swelling and pain management. And we definitely have seen much lower need for narcotic pain medicine, for instance. So, that alone gets people feeling human more quickly and that alone gets people on their feet more quickly, and that translates into a better recovery. So definitely, there is progress being made, not just in the operating room, but with the encompassing package of how do we get back on our feet.

Host: Yeah. So, you said you've been practicing for 15 years now?

Max McCabe, MD: I think this is my 12th year here in Winston-Salem.

Host: So when you were in your residency for Surgery and fellowship for Orthopedic surgery, was robotic-assisted training a part of that? Or is this something so new that you've had to do extra training?

Max McCabe, MD: So, in my fellowship, we got exposure to it. In my residency, I'm glad you brought that up, because we've talked about the robotics. We haven't talked about the other way, which is essentially we have a wider landing zone, let's say, because we don't have the level of precision. So, we can't develop a precision customized plan for alignment or matching someone's own soft tissue anatomy.

And so, essentially, what we used to do is, we didn't put it this way, but we're trying to make everyone's x-ray look the same, regardless of how they started out before their arthritis. And so, in my fellowship, we were doing robotic partial knee replacements and that had its application for sure. But the progress since then has been developing that into a total knee replacement. And in my experience, we're seeing results with the total knee replacement like we used to see with a partial, which is more natural feeling, a little bit easier recovery. And that's how it's expanding.

Host: When you look at a patient, how do you know if they're a good candidate for robotic-assisted or is everybody kind of going down that pathway now?

Max McCabe, MD: The way I look at that is definitely there are benefits for every case, every surgery when we talk about knee replacements. But there are definitely times when it's more important than others. That might be an old injury, right? They may have hardware from prior surgery. There may be some complicated deformity where we really want to take advantage of better measurement, better execution of the surgical plan in the operating room. So, I think there are benefits to every knee replacement. But sometimes it's definitely more important than others. So, we use it on well over 90%.

Host: Oh, really? So, it's that high. Now I wasn't expecting that percent. Wow. You have a patient who's a candidate for this, and you have already mentioned that one of the things that's nice about the robotic-assisted surgery is you're able to kind of configure and meet the anatomy and specific needs of that patient. What does that really mean? How does the robot help you do that?

Max McCabe, MD: So, again, it starts with accurate measurement, which we couldn't do before. And so, we all start out with a certain alignment. In everyday language, some people are more bow-legged and some people are more knock-knee. And that's often very subtle throughout adult life. But then, when you start to get arthritis, it gets more exaggerated. And for some people, it's still correctable, meaning we've developed this deformity. But with a little pressure, we can put it back where it wants to be. And that's relatively simple. But other times that becomes what we call a contracture, meaning the knee is stuck in that position, and they may lose straightening, which we call extension, or they may lose bending of the knee, which we call flexion.

And through this whole system that we call the robotic-assisted knee replacement, we're able to evaluate the tension in the various soft tissues, come up with a plan that should address these, then evaluate that as we go.

Host: And so, when you tell a patient that, "Okay, you're a candidate for robotic-assisted surgery," what's the first question they usually ask you or a couple of questions?

Max McCabe, MD: Well, I try and explain it like we've talked about, where it's really precision measurement and precision tools to execute the plan, rather than I don't want people picturing a Honda assembly line or something like that. It's still very personalized. It's still very hands on. It's still very individual.

Host: Yeah. And then, it sounds great. Outcomes seem to be improving, getting back to normal life quicker, all of that stuff is fantastic. But there are some risks. There's risks with every intervention we do. Anything specific to robotic-assisted surgery?

Max McCabe, MD: Thankfully. I don't think it adds to risk overall. You're right, one thing is we get a CT scan, right? A CT scan is like having many x-rays. So, there's a dose of X-ray radiation. But all things considered, that's a fairly low risk of causing any concerns. And then, we also have to tell the robot where the knee is. And that involves we have to register the anatomy to the surgical plan that we have. The way we do that is we have to put in these pins, which are typically, in my case, I don't do any additional incisions for that. We just do it within the surgical incision. But, you know, anytime you're putting in more hardware, even if it's temporary like this, there's a tiny risk of complications. But, again, I think there are benefits that outweigh these small risks and it's something we just do very carefully.

Host: What about AI? How is that going to play a role now with robotic-assisted surgery? What do you think the future of all this looks like?

Max McCabe, MD: Well, I think AI is probably the next step and what that might involve is I've talked about how we gather the information and customize the plan to suit the individual. I think there's room for analyzing all that data and the software could potentially assist with coming up with that plan. Whether it be more bone preservation, whether it be accounting for something that isn't as obvious in the planes of motion that we're measuring. So, I know this will get deeper and there'll be more levels of information and higher levels of planning that go into executing these plans.

Host: Do you see nowadays-- like, when you started even as a resident to where you're at today, are patients in general becoming more comfortable with the idea of knee replacement surgery and even hip, whatever that may be, robotic or not? Or is the population just becoming a little more comfortable with this?

Max McCabe, MD: I think so, yeah. I think we definitely see friends who have had similar problems and had undergone similar treatments who come in with a lot more information, a lot more understanding of what the options are. So, we definitely see that.

Host: With the patient who's still a little nervous, not quite sure, a lot of pain, you know what's right for them, what do you say to them?

Max McCabe, MD: Exactly what we talked about earlier. Really, this is not my decision, it's a quality of life decision. And so, I try to arm people with the information they need to make a good decision. What are the outcomes? What do we expect life to be like three months, three years after surgery, and try and help people along that path as they're trying to analyze their own situation.

Host: So, any last words for the listening audience that you'd like them to know about what you do, why you went in this field, and how excited you are with robotic-assisted surgery?

Max McCabe, MD: Well, I went into this field because it's really exciting to be able to do something that really gives someone a sense of getting their life back. So, I really enjoy it. And I think the main message, I think, is I'm a big fan of this approach that we're doing. I think it really is improving things, but I think I still would tell someone the most important thing is having a good relationship and trusting that your doctor and you are on the same page. I think that's the most important. And I like to talk about that sort of thing with patients so they make sure that our goals are the same and our expectations are the same. And we utilize the best technology where we can. But always remember the big picture.

Host: Fantastic. I love this great conversation with you. Dr. Max McCabe, thanks for coming on.

Max McCabe, MD: Yeah, it's been fun. Thanks For your time.

Host: For more information, you can head over to novanthealth.org or explore more health insights on healthyheadlines.org. If you like this podcast, please go ahead and share it on your network and take a look at our podcast library for topics that might be of interest to you. This is Meaningful Medicine. I'm Dr. Mike. Thanks for listening.