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Computer Navigation in Shoulder Arthroplasty
Thomas Wright, MD, and Jay King, MD, discuss computer navigation in shoulder arthroplasty and why this type of navigation can be more beneficial than using traditional instruments in shoulder arthroplasty. They also share their thoughts about the future of shoulder arthroplasty surgeries.
Featuring:
Learn more about Thomas Wright, MD
JOSEPH J. KING, III, M.D., earned his medical degree at Drexel University in 2006 before going on to complete his residency in Orthopaedic Surgery at the Drexel University and his Clinical Research Fellowship in Orthopaedic Oncology at the University of Pennsylvania.
Learn more about Jay King, MD
Thomas Wright, MD | Jay King, MD
Thomas W. Wright, MD, received his bachelor's degree from Emory University and then attended the University of Florida, where he obtained his medical degree and graduated Alpha Omega Alpha. AOA is a medical honor society representing the highest ideals in medicine. Only the top ten percent of medical students are eligible to be elected to AOA.Learn more about Thomas Wright, MD
JOSEPH J. KING, III, M.D., earned his medical degree at Drexel University in 2006 before going on to complete his residency in Orthopaedic Surgery at the Drexel University and his Clinical Research Fellowship in Orthopaedic Oncology at the University of Pennsylvania.
Learn more about Jay King, MD
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to join us as we explore computer navigation in shoulder arthroplasty.
Joining me in this panel today is Dr. Thomas Wright. He's a professor in the Department of Orthopedic Surgery and Sports Medicine, and Chief of the Division of Hand and Upper Extremity at the University of Florida College of Medicine, and he practices at UF Health Shands Hospital. And Dr. Jay King, he's an Associate Professor in the Department of Orthopedic Surgery and Sports Medicine and the Division of Hand and Upper Extremity at the University of Florida College of Medicine. He also practices at UF Health Shands Hospital.
Gentlemen, I'm so glad to have you join us today. And this is a really great topic. So Dr. King, I'd like to start with you. Can you just give us a little overview of the indications for shoulder arthroplasty and why you would seek this for patients?
Dr Jay King: Thank you, Melanie. I appreciate the opportunity to talk to you guys today. The indications for shoulder arthoplasty are someone with a painful shoulder that has shoulder arthritis associated with it, which is the cause of their pain. And we seek this for patients and people that have had pain for generally a long time or progressive increase in pain that have tried non-operative management and have not responded to non-operative management and continue to have significant shoulder pain with imaging findings of shoulder arthritis.
Dr Thomas Wright: Jay, let me add that also we use shoulder arthroplasty in patients who have deficient rotator cuffs that are not repairable, that can't be surgically repaired. And there is a specific implant designed to bypass the rotator cuff and manage that particular problem. So that's a little different population.
Dr Jay King: I can add too that the primary indication is that there are also several other indications, including a failed prior fracture surgery, prior fractures, and there's several other indications too, but these are the most common, the ones that Dr. Wright and I mentioned.
Melanie Cole (Host): Well, I'm so glad that you both brought that up because I was going to ask about injuries and where that fits in versus chronic pain and problems. So thank you for clearing that up. And Dr. Wright, would you define a little bit about computer navigation and shoulder arthroplasty? What's the role of robotics for shoulder surgery and how has this evolved over the years? Because it's really an exciting time for this technology.
Dr Thomas Wright: Yes, thanks, Melanie. This came about, and the shoulder's not the first place this has been used, it's certainly been used in the spine, it's been used in the knee and is now being used some in the hip. But it's just starting to be used in the shoulder. And there's a lot of reasons for that. The shoulder is fairly complex. But the reason behind this is that when a surgeon is actually replacing a joint, the shoulder joint, they can't see the orientation or the shoulder blade, which is where we put some of the implant. And therefore, we're kind of guessing. Because this shoulder blade is covered with soft tissues, we can't see it. However, using a CT scan, a CAT scan, which takes slices through the bone, it can then be used, when you marry it with a camera, you can know exactly where you are and you can put the implant in very precisely. And we've been using this for approximately three or four years. I've done a little under 600 cases with the computer navigation.
Melanie Cole (Host): Wow. So Dr. King, tell us about some of those benefits as Dr. Wright just mentioned, the shoulder has such complex movements. Tell us a little bit about the differences compared to traditional instrumentation. Can you compare and contrast these and tell us the benefits, both for the patient, but also for the surgeon?
Dr Jay King: So the biggest issue with placement of shoulder arthroplasties like Dr. Wright mentioned is placement of the socket, the glenoid component. Because you cannot see the shoulder blade, it's difficult to find where the good bone is. This is constantly our problem in shoulder arthroplasty, both for the patients, because if you don't have good fixation, you tend not to have a good outcome and can have complications, and also for the surgeon to make the surgery go faster, which also leads to less complications.
So the ways to do this are just basically by site, that's how we used to do it. We would usually get a preoperative CT scan anyway to look at the bony anatomy and then kind of correlate that in our mind to the patient. Current other ways to do that are specific instrumentation that can be made. So your CTs can be uploaded to a system. There's computer programs that make a little guide that you can use during surgery, mostly that is used to place just the center pin for the glenoid, which can be helpful. And you can also just use preoperative planning, where basically you can put the implants in a computer model and space, and that gives you a little bit more understanding of where to put it during surgery.
But none of those options you can change very easily and are not as accurate as the computer navigation, which basically is able to put the implant right where you planned it. Not only the main fixation of the implant, the center cage, but also the screws and the orientation of the implant as well. That's what the computer navigation allows us to do, which these other things, parts of that, that are unable to be changed during the procedure.
The benefits to the patient would be better placement of the implants and more accurate implant placement, which can lead to hopefully better outcomes and less complications in the long-term.
Melanie Cole (Host): Dr. Wright, this is fascinating. And as Dr. King was just speaking about in those complex movements, evaluate for us the learning curve for other surgeons that are looking to perform computer-navigated shoulder arthroplasty. I mean, it certainly depends upon the individual surgeon's surgical skill and experience, right? But can you give us a little bit of an overview of some of the technical aspects and predictors for successful surgery? What was your learning curve and some of the barriers?
Dr Thomas Wright: Melanie, the learning curve for shoulder replacement is very steep and very long. And the idea behind computer navigation and interoperative navigation is to flatten that curve, make it very short because invariably, with long painful learning curves, there are complications and we want to minimize those.
So in the past, I would say that you probably needed about a hundred of these to get pretty good and without computer navigation. Now, the learning curve with the computer navigation is about five cases. So it's not very long at all. And it allows even inexperienced surgeons, relatively inexperienced surgeons, to do very, very high quality work. It's a big game changer.
Dr Jay King: I would like to add to that too, we actually looked at this in our patients. We did the traditional three-dimensional preoperative planning. We planned all the placement of the glenoid component in a patient. And then when we went to the OR, we used the navigation equipment to see if we didn't have navigation how good we were. And even us, Dr. Wright and I, Dr. Wright has definitely done more cases than I have, but relatively experienced surgeons, in about 40% of the cases, we were significantly off with what we had planned based on that. So, even with all the three-dimensional imaging, without the guidance during surgery, we were still not perfect in placement, and that is with experienced surgeons.
Dr Thomas Wright: Yeah, let me add to that too, Jay, I had a conference earlier today, gave a talk on this and it was not like we weren't very good, we were pretty bad, and that was after me doing several thousand. We still had errors of over plus or minus 12 degrees, which is a lot. So even in experienced hands, our standard deviations as far as implant placement is really tight now. So it's not just the inexperienced surgeon, even the experienced surgeons can be made better. So thank you for adding that.
Melanie Cole (Host): Well, thank you both because this is really fascinating and so helpful for other providers. So Dr. King, speak about some of the current limitations as we've talked about experience and skill and really what comes down to practice as you were both discussing. Speak about some of the limitations that you're recognizing now that you're hoping will get ironed out and some of the future directions for shoulder arthropathy.
Dr Jay King: Our hope for the future is that we build on this computer navigation of the glenoid and we're able to also add to the humeral component placement and humeral component planning, which is already in stages in some systems. The other thing is knowing how we're putting it in and how that affects the ultimate outcomes. That's our big goal. Because if we know if we can put it in a certain way and we can gain extra motion or extra function for patients, that's going to help us in the future place it even better. And now we have a very good way to identify how we're placing it and where to place the implants.
So that's the ultimate goal, to know where the ideal place is and ideally for every patient, almost like patient-specific surgery. If someone needs more motion in one plane, we might know what angles we could put the implants in to try to gain in that motion. That's our ultimate goal in the future, which, honestly, as we do this more and more, we're getting closer and closer to that.
Melanie Cole (Host): Well, you certainly are. And as I've said, it's such an exciting time for this technology. And Dr. Wright, last word to you. Can you give us some thoughts about the future of shoulder arthroplasty and surgeries, and what you would like referring physicians to know about the exciting work that you are doing at UF Health Shands Hospital with computer navigation in shoulder arthroplasty?
Dr Thomas Wright: The first thing, shoulder arthroplasty makes a huge difference in a person's life. When you have pain that's so severe that you can't sleep at night, it's always grinding away at you, and you can take that pain away, which shoulder arthroplasty can do, you can make a tremendous improvement in someone's life. So that's number one.
The future holds, I think what's going to happen is computer navigation will evolve further. We actually may be able with 3D printing make custom implants that fit the person perfectly by just taking the CAT scan, making the implant and be able to navigate it and put it in place. We're currently able to do that actually, but it's very, very expensive. But with time, I think that will come down and that'll make a difference particularly on people who've had multiple failed arthroplasties where there's very little bone to help hold the implant in place.
So this technology is still rapidly evolving. In fact, this afternoon, I got a call in with a French company that we're about to roll out the navigation on the humeral side. So we're really close there. And that's going to add to this whole improvement, I think.
So the bottom line is we want to be able to look a patient in the eye that's miserable, and tell him with the 90 plus percent chance you're going to feel a lot better and you're function is going to improve as well.
Melanie Cole (Host): Wow. Thank you so much, doctors, for joining us today. What a great technology and an amazing time to be in your field. And thank you so much for sharing your expertise and experience with us today.
To refer your patient to Dr. Thomas Wright or to Dr. Jay King or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please always remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to join us as we explore computer navigation in shoulder arthroplasty.
Joining me in this panel today is Dr. Thomas Wright. He's a professor in the Department of Orthopedic Surgery and Sports Medicine, and Chief of the Division of Hand and Upper Extremity at the University of Florida College of Medicine, and he practices at UF Health Shands Hospital. And Dr. Jay King, he's an Associate Professor in the Department of Orthopedic Surgery and Sports Medicine and the Division of Hand and Upper Extremity at the University of Florida College of Medicine. He also practices at UF Health Shands Hospital.
Gentlemen, I'm so glad to have you join us today. And this is a really great topic. So Dr. King, I'd like to start with you. Can you just give us a little overview of the indications for shoulder arthroplasty and why you would seek this for patients?
Dr Jay King: Thank you, Melanie. I appreciate the opportunity to talk to you guys today. The indications for shoulder arthoplasty are someone with a painful shoulder that has shoulder arthritis associated with it, which is the cause of their pain. And we seek this for patients and people that have had pain for generally a long time or progressive increase in pain that have tried non-operative management and have not responded to non-operative management and continue to have significant shoulder pain with imaging findings of shoulder arthritis.
Dr Thomas Wright: Jay, let me add that also we use shoulder arthroplasty in patients who have deficient rotator cuffs that are not repairable, that can't be surgically repaired. And there is a specific implant designed to bypass the rotator cuff and manage that particular problem. So that's a little different population.
Dr Jay King: I can add too that the primary indication is that there are also several other indications, including a failed prior fracture surgery, prior fractures, and there's several other indications too, but these are the most common, the ones that Dr. Wright and I mentioned.
Melanie Cole (Host): Well, I'm so glad that you both brought that up because I was going to ask about injuries and where that fits in versus chronic pain and problems. So thank you for clearing that up. And Dr. Wright, would you define a little bit about computer navigation and shoulder arthroplasty? What's the role of robotics for shoulder surgery and how has this evolved over the years? Because it's really an exciting time for this technology.
Dr Thomas Wright: Yes, thanks, Melanie. This came about, and the shoulder's not the first place this has been used, it's certainly been used in the spine, it's been used in the knee and is now being used some in the hip. But it's just starting to be used in the shoulder. And there's a lot of reasons for that. The shoulder is fairly complex. But the reason behind this is that when a surgeon is actually replacing a joint, the shoulder joint, they can't see the orientation or the shoulder blade, which is where we put some of the implant. And therefore, we're kind of guessing. Because this shoulder blade is covered with soft tissues, we can't see it. However, using a CT scan, a CAT scan, which takes slices through the bone, it can then be used, when you marry it with a camera, you can know exactly where you are and you can put the implant in very precisely. And we've been using this for approximately three or four years. I've done a little under 600 cases with the computer navigation.
Melanie Cole (Host): Wow. So Dr. King, tell us about some of those benefits as Dr. Wright just mentioned, the shoulder has such complex movements. Tell us a little bit about the differences compared to traditional instrumentation. Can you compare and contrast these and tell us the benefits, both for the patient, but also for the surgeon?
Dr Jay King: So the biggest issue with placement of shoulder arthroplasties like Dr. Wright mentioned is placement of the socket, the glenoid component. Because you cannot see the shoulder blade, it's difficult to find where the good bone is. This is constantly our problem in shoulder arthroplasty, both for the patients, because if you don't have good fixation, you tend not to have a good outcome and can have complications, and also for the surgeon to make the surgery go faster, which also leads to less complications.
So the ways to do this are just basically by site, that's how we used to do it. We would usually get a preoperative CT scan anyway to look at the bony anatomy and then kind of correlate that in our mind to the patient. Current other ways to do that are specific instrumentation that can be made. So your CTs can be uploaded to a system. There's computer programs that make a little guide that you can use during surgery, mostly that is used to place just the center pin for the glenoid, which can be helpful. And you can also just use preoperative planning, where basically you can put the implants in a computer model and space, and that gives you a little bit more understanding of where to put it during surgery.
But none of those options you can change very easily and are not as accurate as the computer navigation, which basically is able to put the implant right where you planned it. Not only the main fixation of the implant, the center cage, but also the screws and the orientation of the implant as well. That's what the computer navigation allows us to do, which these other things, parts of that, that are unable to be changed during the procedure.
The benefits to the patient would be better placement of the implants and more accurate implant placement, which can lead to hopefully better outcomes and less complications in the long-term.
Melanie Cole (Host): Dr. Wright, this is fascinating. And as Dr. King was just speaking about in those complex movements, evaluate for us the learning curve for other surgeons that are looking to perform computer-navigated shoulder arthroplasty. I mean, it certainly depends upon the individual surgeon's surgical skill and experience, right? But can you give us a little bit of an overview of some of the technical aspects and predictors for successful surgery? What was your learning curve and some of the barriers?
Dr Thomas Wright: Melanie, the learning curve for shoulder replacement is very steep and very long. And the idea behind computer navigation and interoperative navigation is to flatten that curve, make it very short because invariably, with long painful learning curves, there are complications and we want to minimize those.
So in the past, I would say that you probably needed about a hundred of these to get pretty good and without computer navigation. Now, the learning curve with the computer navigation is about five cases. So it's not very long at all. And it allows even inexperienced surgeons, relatively inexperienced surgeons, to do very, very high quality work. It's a big game changer.
Dr Jay King: I would like to add to that too, we actually looked at this in our patients. We did the traditional three-dimensional preoperative planning. We planned all the placement of the glenoid component in a patient. And then when we went to the OR, we used the navigation equipment to see if we didn't have navigation how good we were. And even us, Dr. Wright and I, Dr. Wright has definitely done more cases than I have, but relatively experienced surgeons, in about 40% of the cases, we were significantly off with what we had planned based on that. So, even with all the three-dimensional imaging, without the guidance during surgery, we were still not perfect in placement, and that is with experienced surgeons.
Dr Thomas Wright: Yeah, let me add to that too, Jay, I had a conference earlier today, gave a talk on this and it was not like we weren't very good, we were pretty bad, and that was after me doing several thousand. We still had errors of over plus or minus 12 degrees, which is a lot. So even in experienced hands, our standard deviations as far as implant placement is really tight now. So it's not just the inexperienced surgeon, even the experienced surgeons can be made better. So thank you for adding that.
Melanie Cole (Host): Well, thank you both because this is really fascinating and so helpful for other providers. So Dr. King, speak about some of the current limitations as we've talked about experience and skill and really what comes down to practice as you were both discussing. Speak about some of the limitations that you're recognizing now that you're hoping will get ironed out and some of the future directions for shoulder arthropathy.
Dr Jay King: Our hope for the future is that we build on this computer navigation of the glenoid and we're able to also add to the humeral component placement and humeral component planning, which is already in stages in some systems. The other thing is knowing how we're putting it in and how that affects the ultimate outcomes. That's our big goal. Because if we know if we can put it in a certain way and we can gain extra motion or extra function for patients, that's going to help us in the future place it even better. And now we have a very good way to identify how we're placing it and where to place the implants.
So that's the ultimate goal, to know where the ideal place is and ideally for every patient, almost like patient-specific surgery. If someone needs more motion in one plane, we might know what angles we could put the implants in to try to gain in that motion. That's our ultimate goal in the future, which, honestly, as we do this more and more, we're getting closer and closer to that.
Melanie Cole (Host): Well, you certainly are. And as I've said, it's such an exciting time for this technology. And Dr. Wright, last word to you. Can you give us some thoughts about the future of shoulder arthroplasty and surgeries, and what you would like referring physicians to know about the exciting work that you are doing at UF Health Shands Hospital with computer navigation in shoulder arthroplasty?
Dr Thomas Wright: The first thing, shoulder arthroplasty makes a huge difference in a person's life. When you have pain that's so severe that you can't sleep at night, it's always grinding away at you, and you can take that pain away, which shoulder arthroplasty can do, you can make a tremendous improvement in someone's life. So that's number one.
The future holds, I think what's going to happen is computer navigation will evolve further. We actually may be able with 3D printing make custom implants that fit the person perfectly by just taking the CAT scan, making the implant and be able to navigate it and put it in place. We're currently able to do that actually, but it's very, very expensive. But with time, I think that will come down and that'll make a difference particularly on people who've had multiple failed arthroplasties where there's very little bone to help hold the implant in place.
So this technology is still rapidly evolving. In fact, this afternoon, I got a call in with a French company that we're about to roll out the navigation on the humeral side. So we're really close there. And that's going to add to this whole improvement, I think.
So the bottom line is we want to be able to look a patient in the eye that's miserable, and tell him with the 90 plus percent chance you're going to feel a lot better and you're function is going to improve as well.
Melanie Cole (Host): Wow. Thank you so much, doctors, for joining us today. What a great technology and an amazing time to be in your field. And thank you so much for sharing your expertise and experience with us today.
To refer your patient to Dr. Thomas Wright or to Dr. Jay King or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please always remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.