Orthopedic surgeon Daniel Buchalter, MD, has been on the forefront of orthopedic technology in his training and early career.
Dr. Buchalter of Carmel, N.Y.-based Somers Orthopaedic Surgery & Sports Medicine Group, part of Health Plus Management, discussed the orthopedic technologies he thinks will rise and how the healthcare landscape will adapt.
Note: This conversation was lightly edited for clarity.
Question: Can you talk about some of the technologies you're using in your practice, and what's really exciting you in that realm?
Dr. Daniel Buchalter: I consider myself very lucky. At New York City-based Hospital for Special Surgery, I got to train with the designers of the design rationales for the robotic systems and implants that are used every day around the world. That opportunity gave me the chance to truly, from the ground up, understand the way that our implants and surgical technologies work, including the history of their design and the goals that our profession has for them in the future. With that training, I'm very excited to be able to offer patients cutting-edge cementless total hip and knee replacement designs, advanced minimally-invasive approaches, and computer- and robotic-assisted technologies to perform precise and accurate primary and revision joint replacements.
Some specific future technologies that are exciting are the introduction of augmented reality and artificial intelligence in total joint replacement. While still very early in its development, as we pair augmented reality with current robotic and computer platforms, I think that there is a huge opportunity to improve not only the care of our patients, but also the training of medical professionals and the teaching of patients.
Additionally, at some point in the not too distant future, artificial intelligence will enable us to properly interpret all of the sophisticated data that we collect before, during, and after each technology-assisted joint replacement that we perform. I feel strongly that through the use of computer or robotic surgical technology, AI will help standardize the way that we treat all of our patients, leading to both more efficient care and better outcomes.
Q: It sounds really exciting being behind the scenes at that ground level. What are some of your predictions on what the next generations of these technologies will look like?
DB: For implants, I think the next generation, and in some instances the current generation, is in the use of cementless implants for all patients. While cemented technologies have outstanding track records, and current cementless implants, for the knee specifically, may not be a one-size-fits-all design, there is certainly a movement in our profession towards cementless implants from both an efficiency and longevity standpoint. With our active patients undergoing joint replacements at younger and younger ages, it is important that we use "lifelong" implants that can incorporate into a patient's bone--implants that won't loosen or fail at an increasingly unnecessary cement interface. Cemented implants depend on a meticulous cementation technique. And while most orthopedists are well-trained in these techniques, there remains room for human error. The use of cementless implants, with the precision and accuracy of computer or robotic technologies, in my mind, can lead to more consistent surgical execution, more reliable longevity — albeit yet to be proven — and most importantly more consistent outcomes for patients. The addition of AI to guide surgeons in optimizing implant positioning, will drive our profession even further forward.
For robotic technology, in addition to the implementation of AI, I believe the next generation will incorporate what is called array-less technology. Right now, all robotic systems, whether for joint replacements or spine surgery, require what are called arrays. Arrays are implanted into the bone, outside of the surgical site, and have these little trackers that the robotic camera uses to track where the patient's skeleton is at all times.
Arrays have all sorts of issues. One, they add trauma to both the soft tissue and bone, as they either require a larger incision or are placed at a separate location from the surgical site altogether. Two, they can move which throws off the entire operation and either requires a re-registration of the patient's anatomy, or if unnoticed can lead to surgical error. Three, if anything or anyone gets between the array and the robotic camera, the robot cannot function. We have to very specifically set up the operating room in sometimes non-ergonomic ways and our assistants have to contort themselves to stay out of the way of the arrays. Some attempts to improve this have been with the use of radar rather than optical arrays, where the robot knows where the arrays are in space without needing to actually see them with a camera. While this eliminates the line of sight issue with optical arrays, it still has the drawback of requiring separate or longer incisions, and the array can still be bumped or moved.
Alternatively, some companies have begun working on array-less technology, where the robot or computer system can look directly at the surgical field itself, either through a camera in the room or mounted on the surgeon themself. This sort of technology, in my mind, would be a major step forward for robotic technology from a surgical efficiency, consistency, and ergonomic standpoint. Array-less technologies being as ubiquitous and accurate as using optical arrays, I believe, is simply a matter of time.
Q: How have you approached learning these robotic navigation technologies while also making sure you're not becoming over reliant on it?
DB: When I was applying to fellowship, there were fellows that clearly gravitated toward programs that either had more robotics or more manual instrumentation training. And that appeared to be directly related and opposite to what type of training they had in residency. The residency programs that had a lot of manual joints graduated fellows who wanted more robotic exposure, and vice versa.
For my generation, I think that is smart because right now we are still trying to figure out which technique leads to the best outcomes for our patients, which technological platform is the most cost-efficient, and what system is the least burdensome for the healthcare system as a whole. Additionally, knowing how to do joint replacements manually and with technology is critical as many graduates don't necessarily know where they are going to work and what platforms will be available to them.
Historically, we used to ask "what if the robot breaks?" With the obvious answer being then you need to do a manual joint replacement, or you need to find another robot. Throughout my training and early career, I really have not seen that, and believe it is becoming an exceedingly irrelevant argument.
I think the future of it all is similar to the way that everybody used to know how to ride a horse, and then when cars came out, people said, "what happens if your car breaks down and you don't know how to ride a horse?" Well, I don't know very many people in New York City or elsewhere who know how to ride a horse, and they get around just fine. My point is that technology advances to such a stage that saying "you need to know how to do something because what if" becomes irrelevant. I feel lucky in that I graduated residency from a program where I got a lot of both, and was fortunate enough to train at a fellowship program that also offered both.
Q: Where do you see the role of regenerative medicine evolving in joint care?
DB: The reprogramming of skeletal stem cells to prevent or reverse degenerative changes leading to arthritis is an active field of study, but unfortunately appears to be decades away from replacing joint replacements as the standard of care for treating end-stage arthritis.
Sort of along those lines, data on intra-articular stem cell injections like amniotic tissue, or PRP or BMAC injections while seemingly all safe, does not appear to meaningfully alter the progression of arthritis in patients. As our understanding of the biological process of arthritis and the science of these treatments improve, I believe there will be a role for the use of regenerative medicine in arthritis care, first as a preventative strategy, and then wishfully as a reversal-type treatment strategy.
All that being said, we do currently have great options for younger patients with isolated cartilage defects in otherwise healthy joints, such as using osteochondral plugs or even lab-grown cartilage. Hopefully, regenerative medicine can help us bring some of that "biologic" success to our older arthritis patients.