Ep5 - Less invasive hip & knee replacement and enabling technologies with Dr. Cory Calendine
hey what's up? welcome to the Less Invasive podcast; this is another episode of this podcast about minimally invasive surgery and assistive technologies for the operating room and Radiology environment I'm your host Lucien Blondel co-founder and CTO of Quantum Surgical a startup commercializing the Epione robot for percutaneous tumor ablation oI bring 20 years of experience in imaging and robotics for orthopedics neurosurgery spine surgery and Interventional Radiology to the table and today I'm very honored to have Dr Cory Calendine on the show. Dr Calendine is a board-certified orthopedic surgeon practicing at the Bone and Joint Institute in Tennessee he's doing mostly hip and knee replacement he will talk about that and he's also a technology enthusiast having done some work on robotics at the beginning and then procedural telemedicine in and virtual reality we'll talk about that for sure. Dr Kennedy thanks so very much for taking the time on the 4th of July to speak with me, how are you today Lucien, thank you so much it is 4th of July here in the U.S, it's still early the family is still asleep, so the timing's just perfect thank you for making time for me. Rhank you so you've
been on a several series of podcasts; the last one I highly recommend to the listeners to listen to It's called The Slice it's a brand new podcast from Dr Justin Barad founder and CEO of Osso VR talking about innovation in healthcare and you explain your story around how you came to medical with your brothers; one is pediatrician and the other one is radiologist I won't say what you say about this brother; your father is a preacher and one of your mentors was a cardiologist; all this ecosystem of people kind of influenced you towards having the willingness to heal people and to impact their life when they are in pain mostly; so that's how you came to medical school and then you choose to be the bone doctor or so being the cutter and then all the rest that you've done. I want to maybe ask you this first question: in your LinkedIn profile and in your posts sometimes you put the hashtag Savoring Life To The Bon, which seems to be your life's philosophy, so why do you do that? what does it mean for you? and how do you live to that motto in your own daily life? yeah thanks so much Lucian yes Savoring Life To The Bone you know savoring for me has a special significance you know it's that concept of maybe enjoying too much a piece of steak or or a vegetable if you're a vegetarian but but there's some element of really enjoying the moment that you're in and and that's what I want to make my life about you know you mentioned some of why I went into medicine I I would tell you look it could have been medicine it probably could have been some other fields too but I knew early on that I wanted my life to face away from me because I really thought that's where fulfillment was and so you you talked around those you know my dad being a preacher I can't remember if I mentioned this before but the reality is is I'm pretty sure my parents are still disappointed in me for not going more deeply into more spiritual Ministry but I think it's up to each of us to have a spiritual life so for me savoring life to the bone is a spiritual experience and it just so happens that my AI profession faces away from me and that that's what I've found so rewarding okay thanks so there is another hashtag that sometimes you put right after this one which is imposter syndrome which can which is kind of curious because you're uh you're uh you know a well-known surgeon uh your voice into space and um I think it would be good for listeners to understand why you would feel this kind of a feeling uh having the Imposter syndrome to maybe when you speak or when you talk on social media I don't know well I you know honestly I I think it comes out of gratefulness like I have a deep appreciation that I am not here by myself that there are other people that excel in skills that I don't have they're smarter they're better looking um you know they're that they have unique skill sets and so I think that's the reality is we all bring this uh unique mix my knowledge may be at some level but my ability to communicate may be higher you you get the idea and so if you're willing to put yourself out there I think you're always going to find people that are smarter than you better communicators than you funnier than you more more Forward Thinking than you and you can allow that to discourage you but for me I kind of embrace it you know imposter syndrome for me I know it's supposed to be a negative like I don't belong here and I absolutely feel like that but I see imposter syndrome as look I have an appreciation for all the greatness around me and you know what that does that allows me to get myself out of the way so I'm okay with that I don't have to be the man it allows me to get myself out of the way and really sit back and say man what can Lucian teach me and and I don't want to miss that you have 20 years of experience solution I would not know you had I not put myself out there on LinkedIn look there are surgeons that should be posting on LinkedIn that aren't okay and we're going to talk about social media but the reality is is I had to get comfortable with where I was whether I felt like I had arrived or tip of the spear or however whatever phrase you want to put to it I am an unfinished uncooked product and that's okay with me because it allows me to be around these kind of incredible people Lucian quite frankly uh like yourself I I've really enjoyed getting to know you and see what you do and and understand your realm you know this uh needle and a breathing patient to jab it into the liver listen and respect my friend but why you wanted why you want to talk to me I still don't know but I think it's the coolest thing and I'm super thankful for it so thank you yeah thank you very much I mean I I love this mindset uh basically I think Germany's were saying the same thing uh that we are all work in progress and we just have to acknowledge that and that that makes us in a a more comfortable position because we can improve and there is not that much expectation on ourselves we just do what the best we can uh with the good intention and and the right mindset so I'm uh I'm uh I'm all aligned with that and uh why do I uh want to do on the show I mean this is uh I think it's all about communicating because uh you what you do on social media and and and and what you do on new technologies uh is is part of um promoting this this Technologies uh promoting the debate accepting the debate and and May make things better so for the industry for the Physicians so there need to be some discussion between Physicians and Industry and and not specifically in one space that that maybe it's only new replacement or only liver cancer I mean those technology we know they surgeon faces the same challenges and Hospital faces the same challenges so we have to to talk about that and on a more uh broader scale than just a one specific indication so that's one that's one reason the other is that those three technologies that you are working with robotics virtual reality telemetic I'm a big fan of all those three so my goal at the end is not to create a technology I don't really care much about the technology it's to provide a product for the end user the end user is you so I need to understand what the end users think about this technology what is expecting what is lacking today what's the future so that we can design a better product not not necessarily a better technology but a better product for the position for the surgeon for the radiologist to help treat more patients or patients that cannot be treated today well no I think that's absolutely true and wasn't it Steve Jobs that said you know um you know we're here to make a dent in the universe you know I I have said previously if you want to make a dent in the universe you better swing the hammer and that that swing it and and if you don't feel like you're good enough guess what you're not but the people beside you will help you and you're right we all get in our little silos liver cancer or you know bones and joints or however we want to quantify it but we're all dealing with the same problem so so so how are we going to interface together how are we going to gain from each other we got to connect and listen that brings us here yeah cool so I've got a last question for you uh I think I've seen I've seen a tick tock videos uh you mentioning that um surgery can be a lot of stress especially when it comes to fractures or difficult joints or revision surgery how do you handle stress before and during surgery I mean this is not really much spoken about I mean people spoken of the outcomes patient reported outcomes and their techniques and instrumentation and our Technologies not many surgeons speak about the level of stress they face and how they deal with that and I I do I do think that everybody's got to have some stress to be a you know really focused on what they will be doing and I'm curious about how you handle that well I mean stress I I I wonder why it's a good question why don't we talk more about the stress in the operating room one reason maybe is that I don't know of a way to articulate it to you you know it takes a certain type of person to to take a blade to take a scalpel to someone else's skin there's a real I guess you could develop a real arrogance around that but but it's forced me kind of the opposite way it's uh it's forced me towards a real humility that the fact that someone would lay down in front of me and say uh go uh allow me to sedate them let them sleep and then do my very very best for them so I I think there are a lot of reasons why we don't talk about the stress one is I don't know how to articulate it to you the other side of it is look I'm not I have chosen this profession I I would never want anybody to feel like I'm bragging about the stress that I live with each and every day I you know I I chose this but but but I would tell you look and I made this point the other day if you're an accountant I mean what's going to happen like like you're going to move a decimal or something like I mean it's probably recoverable but but in surgery obviously the downside can be catastrophic and quite frankly you know that for patients is what we're talking about the outcome can be catastrophic for the patients but the reality is is that stuff kind of stays you know with a surgeon too so um yeah is it stressful sure how do I manage it I try to be thankful um I try to be grateful that I'm there I I try to educate myself right I spend July 4th hanging out with Lucian uh to try to figure out a way to be better so I I think there is something to that that that that you just want to make sure that you're continuing to work your Craft um and I like the accountability of that but how do I manage it man I work out in the morning I try to eat right I try to get some sleep I try to hug the kids you know you I don't think anybody could do this full-time meaning uh if if all they thought about in life was surgery I think that'd be a pretty miserable existence so people talk about work-life balance by the way Lucian you didn't ask me this but I think that's nonsense I think you have to be a hundred percent into surgery when you're doing it you have to be a hundred percent present with family and over time you know this this concept of you know 60 minutes here 60 Minutes there I don't really understand but as long as you're operating at 100 and doing what you believe in for me that's orthopedic surgery then you're fulfilled and somehow you always have the energy to do more so I I don't really understand the balance I think it's got to be completely out of balance in every moment of every day meaning 100 wherever you are presence is so important yeah be be uh live in the present yeah don't don't think about the best in the in the future too much because uh that's uh that's either done or on that not yet done thanks so we'll move on to uh to search surgery so um we we talked before about the topics minimal invasive surgery when I was in Orthopedics I think it was in 2005 the introduction of Robotics holds some kind of promise to uh to help people transition from open surgery to kind of minimal invasive surgery in total knee replacement during much smaller incision but it was much more challenging to to locate the female or the tibia do the right cuts and and then place the implants and um so when the the robot was called Bridget at the time it was a with a Zimmer project never went to the market but at the time there was the Mako system that that took off with a striker afterwards and when I see pictures of a new replacement right now I feel like we're back to uh some kind of large incisions and that are probably a good reason for that so I wanted to uh hear from you what do you what's the definition of minimal invasive in a knee replacement and and what are the challenges instrumentation could we do can we do less invasive or are we have a reach a plateau yeah minimally invasive doesn't mean anything and um minimally invasive was a term that probably some marketing people came up with and I think to the patient it means a smaller skin incision what the patient doesn't realize is if the surgeon is making a smaller incision in order to make your scar prettier but if that incision threatens your ultimate outcome it ain't worth it right but patients don't see that we always talk about the incision that it's the only thing the patients see so all the real work happens below the incision of course we all know that intellectually but again it is absolutely true the incision is the only thing they see so what does minimally invasive mean it means absolutely nothing to to most people it means a shorter incision but to a surgeon what I'm most focused on is how am I less invasive there's this great podcast that I've heard about called less invasive how do we make it less invasive on the patient now you've done something so minimally invasive I'm not sure what that means knee replacement or hip replacement no matter how it's done you're cutting bone and you're putting metal inside a human body like you can only make that uh so minimally invasive if you will but but solutely make it less and less invasive softer on the soft tissues Etc so the things that you're seeing on YouTube now you can get YouTube and Instagram and all that anybody can watch surgery now but you're seeing larger incisions and oftentimes we do a larger incision to demonstrate them for the video like that that's the truth of it because we want you to be able to see what we're doing but the skin incision length honestly has no impact on the the patient's recovery but they're worried about it and they're concerned and it needs to be acknowledged I'm not trying to make huge incisions on anybody but it's it's far less important than what we do below the skin so robotics which you mentioned this is all about what we do below the skin right the the robotic arm at least in Orthopedics doesn't make the incision that's still the surgeon but it's all about what we do below you know how do we handle the soft tissues the ligaments you know a knee replacement we saved the MCO uh MCL and LCL for sure and oftentimes we'll now save the PCL how do we treat those tissues during surgery how do we cut the bone are we cutting it three times and does the saw go beyond the edge of the bone or are we cutting it once and that saw blade stops at the edge of the bone therefore only violating the tissue that it needs to violate that now that's powerful and so even though you might be seeing larger incisions and the patient might be focused on the incision it's not that we shouldn't care about that but that is far less important to the patient's recovery and honestly to me as the surgeon how are we going to treat the soft tissues below the skin better and with precision and and that that's that's the promise of robotics that's I mean that's a great definition it's a less invasive and the missiles and the ligaments and on the bone which which are which are the elements that makes the joint uh functioning and and what you say the skin pretty much we don't care how many ills uh pretty easily and it doesn't really it's not the same level of function and impact on the patients also yeah I mean it's very important to to to have these distinctions but every every patient that goes through a totally replacement what they will share is a picture of their knee after surgery and all whether and and and I have someone in my family that had this kind of operation uh a couple of months ago and all I can see it's just the incision so you're right that's that's the only thing people see and and we need to educate also what is beneath the skin and why it doesn't matter that much the the length of the of the incision yeah I mean the incision the incision is all they see and you know we say incisions heal side to side not in the end right so never compromise is the skin incision for what you're accomplishing below that incision all right and what what about the the Heap I'm not I'm not much knowledgeable around the hip I've I've worked on a tilt only we started with Zima at that time to to look at application of the robotics for Heap with the reamer you know and the acetabular components so I'm not really knowledgeable or the clinical side so what kind of uh is there different techniques to put a HIPAA hip implant in the patient's body I know there is anterior posterior approach one incision to incision could you just just uh explain the basics for our listeners sure I I mean the approach matters there's a lot of marketing at least in the US about the anterior approach it goes between two muscles that have different nerves that go to them so it's truly at what we call an intern nervous plane for your listeners and so we we think there's less muscle cunning and therefore a little faster recovery with the anterior approach again in the U.S this is becoming popular still probably most tips are done with a posterior approach which is where you take down the shorter external rotators you're kind of going through the back of the hip there are many others you mentioned two incision which was popular in the U.S for a
while largely because those same marketing people came up with that too um and then there's modified hard engine so many others no matter what you do with regard hard to incision or approach you still have to cut the bone right and you still have to get the parts in and so remember how he said robotics is all about Precision it's absolutely true with the hip because the hip is a deep joint you know what I'm you know where I'm going with that solution so some people are deeper than other people you you know what I'm saying and so actually patient overall Anatomy I'm talking about their size of of the of their abdomen their size of their quad muscle this makes the hip dip more difficult to access and what difficulty Insurgent access often can mean is in Precision in placement of components and how those components are placed are very important particularly with regard to dislocation right the ballparking top popping at a socket but also how the the hip feels you know the hip joint really is a ball and socket so you want to get those parts in there correctly in the right orientation with the right center of rotation um of the hip joint so that all the muscles around the joint work and work well and and then the number one complaint the number one complaint after hip replacement is leg length inequality now Lucian I'm going to tell you a secret okay only about 30 percent of the people in the world have the exact same leg lengths but the reality is is they don't know that like they think they have the same leg lengths and so with hip replacement you can adjust leg length it's the number one complete afterwards both apparent meaning they feel like they're out of alignment because the muscles get tighter what have you and actual meaning the surgeon really did adjust the leg length either because they meant to or because they were trying to achieve stability either way that is a critical issue for the patient as far as how they do so robotics is all about Precision no matter what the patient shape is we want the cup in right for dislocation we want the leg links right and again no matter what incision you put on somebody maybe there's some advantages for the anterior approach I'm using more and more of that but it's still a hip replacement right back to that you can only make it so invasive I'm still going to take a saw to the Bone and as you said a reamer it looks like a cheese grater to prepare the acetabulum there are some things that just won't go away with regard to what we have to do all right thanks for the clarification and uh both a heap and Nia surgery so moving on to our robotics we talked about the rabbits a couple of times so I've your uh your perspective with the robotics so far I understand is the around three Peters the first is starting with the truce so you you mentioned the importance of having a city a pre-ap city versus the conventional navigation system that doesn't rely on a 3D images the second one with uh being being able to adjust the plan interoperatively and and the third one is obviously the robotics should help um to accurately execute the plan can you elaborate on this those the three pillars and and how does how does it work in in a totally replacement that you're doing today with the macro system yes so I think you explained it well um you know I do believe in those three pillars I always ask the question have you ever seen a three-legged table wobble and the answer is no because between any three points there's a single plane this is the absolute uh fullness that I learned from geometry as a freshman in high school I remember nothing else but I remember that between any three points there's a single plane so I think as we evaluate robotic systems and I would love to think a little bit more about the cancer uh world and and what quantum's doing and seeing if you're uh signing up for what I believe are the three pillars of Robotics but we know you and you mentioned it we know navigation never took off because we finally proved that it doesn't move the needle with regard to Patient outcome right it doesn't and so I think a big limitation of navigation was you never started with the truth so it's a concept of garbage in garbage out which is as old and as cliche as they come and yet we're still releasing robotic systems right claiming precision and accuracy which are very different concepts as you well know Lucian yeah but but but claiming accuracy and precision but we're taking away the first pillar which is anatomic truth okay now I would tell you how it works for me pre-operative CT scan so I know what the truth is I overly that in the operating room and then in the operating room I I learn about their soft tissues now In fairness currently in the Mako system we don't have pressure data right we don't have pressure data and so there there's a movement here about how tight should I make your knee replacement or how loose should I make your knee replacement and for years I wish I I wish I could bring you to some of these conferences that I go to you'll see one like icon of total knee so you must put it in tight there must be no Motion in the ligaments um and all their patients do great and then you'll see another equal icon say they have to be loose and I mean really loose but balanced right so you want them to match side to side but you want a lot of movement in space now who's right well it's probably not just about laxity and it's probably they're probably declaring to us their end result based on the 200 other things they did during the surgery both being Master surgeons so they've figured out what works in their hands so it's very subjective and I talk a lot about the art of surgery because much of what we do is not science it's art right how tight or loose for example what we're talking about how tight or loose does your knee replacement mean to be we still don't know so with robotics we can finally have that conversation with regard to introducing precision and accuracy again starting with their truth making adjustment to the patient but we still don't know what the pressure is now I'll let your listeners in on a little secret I actually don't think the pressure that we want in a knee is a number like for example there are some people that say oh we want the medial side tighter so we want that to be uh you know 30 Newtons of pressure in the lateral side looser so we want it to be 20. this is a popular concept and far better than what we did even five years ago so salute to the pressure guys but what we probably want is customized pressure to the patient based on their viscoelastic curve of their ligaments boom so we we have no way of achieving that I only say that to your listeners to say hey we have a lot more to achieve in the space but today I have much better information I start with the truth the 3D model I overlay that I adjust based on the ligaments as best I can based on balance that point is still a bit more subjective than I think is ideal but neither of those two pillars matter unless you can execute with both accuracy and precision introducing the robotic arm so Mako has a cutting duel on the end of the arm and I think that's a critical piece all right so um thanks very much for uh for this answer I mean uh interesting inside about uh ligament balancing so coming back to um you know the the very first generation of author Orthopedic robots there were actually automated robots back in the 1992 uh there was those two system robotic and Gaspard that was automated automatically Milling the the femur for the total hip or automatically meaning the femur on the bone for doing the cuts and they never really took off I mean uh they did that was a big controversy around the system and and now we see another wave of a new wave of a system that are trying to automate uh the cuts what do you think about the willingness to automate surgery in especially in Orthopedics and totally replacement well I I think you have to be careful about who's listening Solutions so if there are surgeons listening they want to be in control so you have to be sensitive this concept that you have to leave the surgeon in control now I'm a surgeon and I would tell you the last thing we want is the surgeon to be in control now let's think about that for a second if I have a better more accurate more precise um tool why wouldn't we want the surgeon using that tool of of course we would so so so some of it truly is the surgeon trying to be remain in somewhat control you know Mako in particular it has a haptic guidance system so there's a boundary so because we have the CT scan we know where the edge of the bone is we're talking about soft tissue protection earlier so so it's obviously providing a lot of guidance but still the arm does not move without the surgeon now the reality is is the Mako arm specifically now can move without the surgeon being there but that's not how it was approved through the FDA and that's not how it's been adopted across surgeon field so you know I always give the analogy you remember that Iron Man movie where you know they stole the Iron Man suit and there was one guy in the Iron Man suit and then he controlled all the droids and uh the the the character Hammer says you know there'll always be the need for man in in the field of battle well I think they'll always be the need for a surgeon in surgery but how can we leverage these tools better I think we've got to get used to that now you mentioned predecessor robots I was in South Korea one time lecturing and I gave what I thought was a very moving speech on not only the current but the future of Robotics specifically in total knee replacement and I referenced some of the prior data that was less than desirable regarding some of the automated robots specifically robo-doc uh which goes by a different name now has been very different but specifically I mentioned their paper that showed 10-year data with robodoc no different in patient reported outcomes now I mentioned this in my paper because the point I'm making during my talk is robotics will change the world and this is why we should all move toward it towards it again I thought it was a very inspirational clear talk so I finished the conversation the first man steps the mic any questions from the audience and he says you know robots don't work I just published the 10-year data on robotic total knee it was the guy it was the author of that paper so I think we have to be very very careful about how we look at Robotics and how we talk about them not only historically what you're mentioning some of these active reaming robots but it's probably not whether or not they actively reamed it was what was the capability of the software along with that system whether or not the arm does it actively or passively probably doesn't matter its level of guidance the level of information we're giving it the the ability to customize that to the patient this is where the real value is so so I honestly I think some of our predecessor robots are going to limit how fast we can scale robotics because we didn't have it all figured out but I've also tipped my hand to you and your listeners that I still don't think we have it all figured out but I think we're a lot better it you know when I think about robotics if you just break it down just pull the you know because I just said we're not where we need to be if you just pull all the blocks apart there are limitations of manual instrumentation that are not limitations in the robotic space so I am already better because I'm overcoming limitations of manual instrumentation now will I be better next year than this year the reality is is I will and in fact if you talk about life motivation that's it for me the fact that I can be better tomorrow that I should be better tomorrow that it's my job to be better tomorrow so that I can serve my patients and my family better that's it for me and it just so happens that robotics is a tool that I'm going to use to get there all right so talking about how to become better I think you addressed a little bit you started to address this uh the question around the data I mean uh to be better you have to measure something to measure something you have to have data recorded during the surgery or after the surgery so there is this new kind of implants in uh in a table stem that enables to record uh data uh for post-ap care that eventually will trigger some other to the physician to uh um for the issues with the knee implant but on the other side they have I understand a constraint a limitation that they they need to to cut more bone basically to put the to put the sensor in do you see this kind of uh data being useful in the future for um it is is this the world the the way to go what's your thoughts about the smart talking images listen everybody loves data right so so five years ago everybody loved the word robot now every buddy use the word data oh we we have so many data we have nine million data points uh the the reality is is I don't care about your data like I don't want data I don't want you to tell me more information I don't want to know what I want is I want insights and so obviously collecting data is a part of that pathway and that's where we are right now right so there's a smart implant that you can insert during total knee Zimmer and I believe it's Canary medical I love what they're doing I love the concept but but the truth of it is is I don't care how many steps my patient is taking at day 13. I don't care I said it I don't care until it's connected to an actionable uh Insight right for example if at day 13 based on their you know prior activity level right because it's all got to be personalized to the patient but if on day 13 they haven't achieved 80 percent of their pre-operative steps per day a I know at six weeks they're going to require manipulation okay now I'm interested and so the reality is is we're in this data collection thing and I'm not anti-data I'm All About You Lucian and the companies collecting data I just don't want to hear about it until you can bring me insight and that's really what we have to do in medicine is bring the Insight so so we'll get there I mean obviously data collection and how we do it it needs to be passive that's what I really like about the implantable devices it's passive that battery life is pretty good it's like 10 years of data that's pretty sexy now it only collects a few things currently but we'll get better now there are there are wearable sensors as well now wearable sensors you say okay well you can charge there's some things that you get out of wearable sensors but then you always worry about putting it on the patient right to capture the data so I think it has to be passively collected evaluated through dare I say machine learning and AI you know data uh you know um uh logarithms right so we got to figure that out and then then really we only can talk from the surgeon side when you have the Insight so you know call me later on the data thing okay so what you what you say is uh I mean that's the I understand that's the Jewish thing we should go uh but it's just the beginning it's just we have a tool right now to record the data and then there is still a lot of work to be done to really make sure that we provide as manufacturer uh as little information as possible to the to the physician which is just direct actionable insight for your patient and and not flooding you with the raw data of everything that happens to each of your patients so I think that's the burden is on the manufacturer's shoulders now to uh really make something out of this data that should be relevant for for each patient so kind of customize for the for the patient all right thanks I mean that's uh that's a very interesting and uh moving moving moving on to uh the two other Technologies I'm a big fan uh that's a procedural telemetic and virtual uh reality I will I will start with the telemet soon I think um that was a strong growth of this um technology which is uh basically the zoom for the operating room which enabled to collect uh connect uh surgeon in the operating room with peers uh in other hospitals also with the manufacturers to get support and also to help to train the Pharaohs or other people that want to just see watch a live surgery first question is do you use this technology in your current practice and how how do you use it yes so I I use the Avail system for two main functions currently what one is for education so quite early when I was just demoing it the good thing about Avail the system that I use it's a hardware and a software solution so there are other systems that integrate with the hardware you that you already have and there's some significant advantages to that of course but but this is a this is a kind of a one-piece Hardware software solution so it's literally you plug it in and you have two cameras in the operating room with which the viewer can watch and then obviously I can see what they're watching so I've used it in two ways one I've used it for Education when I first looked at it I actually put out on some you know LinkedIn or something hey guys I'm gonna do a live surgery not with the robotic total knee company that I was performing in surgery with but just to test out this technology my goodness we had people on there from Mexico and turkey and you know all over the place so our ability connect is pretty powerful so I've used it for Education I've used it for uh specifically robotic or Tech I think we went through cementless total knees in Mexico they don't have cementless total needs so they were most fascinated in that in Turkey they're a little bit slower with robotic adoption so anyway the interest of different people were different but education is a tool and also for me rep support so here in the U.S what's happening is you know conventionally we did all our joint Replacements in the hospital that's just not the case patients go home the same day and we're using what we call ases or Ambulatory Surgery centers essentially you can't stay there overnight you can still go home and I realize there's country differences and even Regional differences here in the U.S but that's a big push so we opened a
new ASC so now we're doing our joint Replacements not just at the hospital but also at the ASC so so you're starting to spread your support staff a little bit thin and so we have used our reps to be able to link into our Avail system so that we can ask him a question or they can track what's going on so we've used it for rep support So industry rep support this may be again somewhat National a difference our our reps are with us so whatever company I'm using Striker for example there's a there's usually a physical rep in the room that has some you know some some knowledge about the equipment and if something goes wrong they can help us well now they can do that remotely so for me education and remote rep support is where I see the value all right so that was a I mean uh I fully understand those two uh those two um benefits uh for me uh that that kind of Technology would help me and Engineers uh be educated also on on how surgeon perform their you know daily routine in surgery how they use a robotic system everything that's uh kind of a complex workflow or complex surgical technique I think this kind of Technology would help um have a common understanding of what's the reality what's the grand truth what's the the challenges that the end user is facing uh and that we are trying to solve and to to bring technology uh for the benefit of the certain so I hope this kind of Technology will also um you know bridge the gap between you know Physicians and industries so that not only supporting the cases but also understanding the customers understanding the practice and and do a better design for the product so um yeah no that's a really good point and I probably should have mentioned that so I'm not currently developing a new implant but we just got done with developing a new stem for one of the companies here in the U.S and that's exactly how we use that same technology right so as we started those initial cases we would have the I adopted the technology a little bit later into the product development but we would have them drop in um how how do I hold the handle and am I hitting the the mount from the top or the bottom you know this these nuances that the engineers really don't have any insight in and so no it wasn't like oh every engineer is going to fly down and come to my operating room we had 20 of the best Engineers for for this unnamed company uh watching how I swing the Mallet right and how they're therefore going to change the ergonomics and the and and the hit plate or or I'm gonna complain that man I wish it was like this and they're going to explain to me hey buddy you can't do that and these are the engineering reasons why you can't do that so so collaboration with regard to development I think is also powerful and not just surgeon to surgeon where education comes into play but surgeon to engineer even surge into marketing person right how how do we articulate the benefits of what we're trying to bring the market unless you understand what I think you call the ground truth so that that's a really great Point yeah thanks thanks so the the last technology I wanted to talk about was the virtual reality so you are I think you joined recently the advice Advisory Board of osovia which is one of the three companies developing a virtual reality system for surgical training so maybe the first question is what Drew you to uh this VR technology and what what are the use cases where you see surgeon benefiting from this this kind of Technology yes so that's a great question so I I spend a lot of time in education particularly around robotics so we've talked a lot about Mako and here in the U.S how that is rolled out is you have a proctor so me a guy who knows how to do it uh fly to you or to a national lab and then surgeons who want to learn meet me there so either I fly to their home institution or we meet at a uh um oh a neutral site for a National Lab so we have to get two surgeons together the Proctor and the trainee if you will and then in a cadaver we perform two of these procedures so we all know what happened during covet nobody went anywhere and so there was this huge education deficit massive education deficit regarding how are we going to train people on newer Technologies this was my initial interest and so virtual reality this concept that you could listen I'm not a gamer so the concept I was offended by immediately like I I'm going to put a headset on and play the video game and then I'm going to operate on a patient this sounds absolutely absurd and so in my complete distrust of the entire area of future development I I discipline myself to to meet these guys and you're right there's kind of three big players in the area there are probably nine different companies that I've talked to in the VR space but also uh Oso is is one that really stood out to me uh you mentioned Justin earlier an orthopedic surgeon himself I'm sure that was a obvious connection but you also talk about imposter syndrome I mean the the people that I'm working with at Oso these guys are like you know doing movie uh graphic work like these guys are like uh designers and creators like high level in their field far beyond anything in medicine but they're coming into medicine to give us these realistic experiences right so I was immediately impressed at how real they could make it and and how much it really did uh simulate what I saw so for me it was education how are we going to educate surgeons on particularly my interest was in new technologies and by the way they're always changing like we we have another new platform rolling out on the Mako system it looks totally different the colors are different the workflow is different now now we're going to go back and refine all those people that I've trained over the last seven years and I'm gonna go fly to them again like this just doesn't make sense and so we have to have a better way to train them it's the Fidelity of virtual reality that I was most impressed with the the the the the ability for it to convince me that I'm actually there now there's nothing like touching a patient it will never replace mentorships uh it it may not totally um make cadaver training disappear but I can tell you surgeons that were training on robotics already know how to operate on people we're just treating we're just teaching them the mechanics of tech and that's what it does really good at now future applications uh you'll love this Lucian as a patient you know we we could have the ability to set a proficiency score for your surgeon isn't that interesting so right now it's kind of like hey man he did pretty good in residency good luck to you this is how we do it in the U.S and we take a written test oh good I I'm good at taking a test but there's really no skill proficiency that we have introduced into our what we call board certification again every country is going to be different but in virtual reality listen nobody wants to be better and never make a mistake than a surgeon nobody so surgeons are going to embrace it immediately but oh yeah by the way there are some proficiency standards that we can start to introduce which may help us overall or or who knows Lucian maybe as we mature maybe we lose our surgical skill and in the virtual space you can tell me hey man it's time it's time to hang it up but but I think it's exciting I I see it all as upside again I I don't think anyone is more interested in getting better than the surgeon you talked earlier about the stress and just to close the a loop on that you know I think all of us feel the stress what do we do we try to get better and the ability to in virtual reality get better on your own time as many times as you'll want without the involvement of a patient this is uh immediately appealing to the surgeons so I think there is I think there's great potential there I think we're just scratching the surface honestly and how virtual reality interfaces with augmented reality and how we use augmented reality in the or you know I mean all of these things are blending but for the education piece virtual reality is really cool and and just so you don't beat me to it you know we're not only putting surgeons in virtual reality but we're putting other people in virtual reality too so Engineers can come into the operating room and see how I interface with my scrub tech right we're passing things back and forth like you know what's the workflow so so again it's a it's it just like procedural telemedicine yeah it's a way to bring people together and this this time no patience involved you know it's repeatable it's easy we can be in different countries and experience one room which is incredible so I think VR is here to stay and I think it's only going to expand are you seeing that in in in Francais as well are you seeing it in France as well or no not that much than the that in the US but uh Tiffany I'm a big believer of this kind of Technology especially when it comes to you know you you said it learning robotic technology a workflow for a specific instrumentation could be a minimum Innovative specific instrumentation all this doesn't require to do a cadaver lab or to do a patient I mean uh I mean probably 80 90 of the of the skills can be learned through virtual reality then you have to obviously go through a couple of phases of you know what's the reality and the real Anatomy but I agree with you it's a it's a great way to accelerate the learning curve for everything that's new and there are always new technologies coming to the operating room so there is this kind of cognitive load on the surgeon to learn all those different stuff and each manufacturer each instrumentation each robot at a different workflow and stuff to remember and steps to go through so this kind of uh you know this kind of Technology could really help people learn all these things and and stay up to date on on this thing without having to uh to fly somewhere or to uh to to depend on somewhere else that has the knowledge so I'm I I'm really a big bit around on this technology and I agree with you there is a something blending with augmented reality and we will see more and more of this kind of Technologies interoperatively used for guidance for during the surgery so that's uh that's very exciting for the future and then this may be also combined with robotics and and procedural to limits and so I mean all all those Technologies are here to assist the surgeon and connect people together so that's a that's a great blend of technology that that I see here with the and and as you said it provides data I mean to be better you have to be measurable and and this VR technology enables to measure something maybe it's not the right you know metrics right now and we and and people we have to figure out along the way what's how do you measure uh the skills of the surgeon in virtual reality but that's that's it's going to be a first step and a second step and and we're gonna do better a long time I hope yeah no I I I hope so too and just to talk a little bit further about imposter syndrome you know Mark Zuckerberg has this company you might have heard of uh it used to be called Facebook now it's meta so I was interested why somebody like that right heavily in the tech space and obviously social very different Lucian like we were talking about very different than what you and I do every day okay but they leaned hard into virtual reality so I was interested right I listened to his press conference immediately Lucian I agreed with 70 of it and knew that 30 of it was going to be totally different in our world in our world of medicine in my world of orthopedic surgery so do I have the right to agree with Mark Zuckerberg about anything probably not but where I'm sitting is totally in a different chair than he is so so so that's what it is how are we going to connect better right how how are we going to learn from other people except by connecting so that's what today is for me Lucian so man I appreciate you having me on this on this July 4th sure and and it comes down to social media so we we get connected to us through Linkedin so right now you have uh you have a presence on on many platforms where you're on LinkedIn you're on Twitter you're on Facebook I think you're on YouTube and you are on Tick Tock with like tens of thousands of followers and millions of views so my first question about social media is how do you see this activity having an impact or changing your relationship with your patients well specifically with regard to patients I will not go through a clinic day now without someone coming in I'm meeting them for the first time and the first words out of their mouth is I feel like I already know you so in healthcare it's a lot about trust and developing trust and uh you know we talked about the art of surgery there's a really art of caring for patients and they have to be able to trust you and so social media although not my intention with social media but social media shortcuts that trust development in a very real way so even though it's virtual it has a direct impact on my future connections right I'm I don't want to disappear I I love interacting with people and there's nothing like sitting face to face in Lucia maybe someday we'll be able to do that but but through social media you can shortcut some of that relationship building and it has been a powerful tool so so how has it changed my patient interaction they trust me they know me before they ever see me and you know look that that does provide some Clinic efficiencies which I enjoy right so um but but it also allows me to develop a deeper relation ship in a shorter period of time and honestly that's more fulfilling for me as a surgeon but it's also more powerful for them we know outcomes are directly related to the patient's mindset right what are their expectations do they believe they're going to get better there's all these personality things that you can do on patients if you establish a stronger relationship with a patient they will do better and so through social media I've established some really strong relationships that others will criticize right and I'm okay with that because the the patient themselves benefit because they feel more connected so again it's a connection for me I actually fell into it accidentally we were with Vanderbilt here in the U.S and Nashville area of Vanderbilt's a big name and we went out and partnered with a private hospital so we created the Bone and Joint Institute of Tennessee so this is a totally new we were not new to the area had practiced in this Regional area for a long time at this hospital but it was a new practice and I thought oh my goodness all my patients are going to stay with their built and I'm out and so I got involved on social media really as a way to kind of make sure people knew that I was still there but it's been amazing I mean professionally I link through Linkedin obviously you mentioned some of the other platforms you know Facebook is more patient facing for me and and that's probably where most of my patients are Instagram the ability to connect you know I mentioned turkey and and Greece I don't think I mentioned but uh Turkey Greece and Mexico on that first Avail call those guys all followed me on Instagram so connecting to physicians in other countries through Instagram it's really been powerful and and I don't know what tick tock's about like I don't know I just know that people are listening and if you want to make an impact you have to swing the hammer and that means you have to go to where they are and for whatever reason they're currently on Tick Tock I've never monetized any of that I don't make any money on it I cannot tell you what my return on investment with regard to time I don't spend money it's all organic but I can't tell you the time investment but I can tell you there is massive benefits to patients I just don't know how to measure it yeah I mean I I I I was on the one of your lives on The Tick Tock and that was it was really amazing you you were in between two flights at the airport and just taking those just time off to uh just you know open up alive and and chat with anybody that comes to the the tick tock live and you are answering like hundreds of questions in in 15 minutes with all those patients having you know their own concern about their health or the one of their family members and and I was thinking you know for us a regular normal patient is very difficult you know to be able to access to a surgeon to have a discussion about your case because usually you just have your consultation it's sometimes very short Constitution that there is a lot of data and then you come back home and and this social media activity enables to put a surgeon closer to that patient and have this direct linked and and it may be just a you know answering a couple of questions through life but it it's really make people more accessible and the content that you're providing makes you also more relatable so all this I understand builds uh a much stronger trust uh right before you start actually engaging with the patient uh in a constipation so that I've seen that and I agree with that I'm fully understand uh the benefit that it provides but uh what about time how much time do you spend on and how do you organize to you know manage all these platform and and do all this while you're doing all those hip knees yeah I mean it it helps not to sleep very well uh I I don't sleep very well or long um look it's busy you already mentioned it I jumped on a live in between two flights I I think if it's a priority for you you can kind of find time I I'm I'm not a big believer and oh I don't have time for that if it's important to you you'll find time and so this has been important to me again not because I can measure a direct return on investment because I think it's the right thing because I think it is providing a service and you mentioned earlier you know patients don't have access to surgeons and and and how nice that is that that they can just ask a question in a in a casual environment I think we all have knowledge that other people want right so for me maybe it's a little bit more on the cuff maybe it's a little bit more obvious as a surgeon and by the way we're all going to have aches and pains no matter what it's a guarantee in life and so maybe I'm I'm positioned in a certain spot but I also believe that everybody has great value to everybody else and so I I you've done this solution I would just encourage people to to participate in the conversation and uh contribute where you can and give and I and I think the reality is is that's kind of how we should live that's what's fulfilling to me and so uh I I really enjoyed it not just in my practice but now in social media um the the ability to connect yeah and I think I will just conclude in that I agree with you and that's the power of a tick tock I guess because they they match what people want to share with what we what people are looking to learn and they do the algorithm is doing this very very well that's why the you know there are so many people doing so well on Tick Tock so I want to be mindful of your time uh thank you very much uh Dr hang on it means we will have to um stop the recording but keep discussing offline thank you so much I hope you will have a very nice Fourth of July with your family it was a great talk with you and uh looking forward to uh whatever you will be doing in this Auto space uh with the new technologies thanks so much Lucian good to be with you
2022-11-25 07:18
