The Changing Landscape of Orthopaedic Practice

Brief Intro:

I currently head the joint replacement unit in Tan Tock Seng Hospital (TTSH), Singapore. I am a strong advocate of technology-enabling joint replacements such as computer navigation and robotic-assisted surgeries that can improve patient outcomes and simplify complex surgeries. I am also the Enhanced Recovery After Surgery (ERAS) Clinical Lead for Knee Replacements in my institution.

1. In Your Opinion, How has The Orthopedic Landscape evolved over the Years? What are some of the Advantages of the Current Technological Evolution?

Joint Replacements have always demanded precision, accuracy, and reproducibility, which translate to better longevity of implants and patients’ function. In our institution, we started from conventional knee replacement methods involving “eyeballing” the bone cuts to having most of our primary joint replacements done using computer navigation or robotics in 2021.

Over the last couple of years, the most significant technological revolution in the orthopaedic landscape has been all about robotics, which promises even better accuracy and precision. Combined with Enhanced Recovery After Surgery (ERAS) protocols, this has translated to better outcomes and fast-tracked ambulatory surgery joint replacements worldwide.

The current application of robotics is predominantly in the field of unicompartmental knee replacement (UKR), total knee replacement (TKR), total hip replacement (THR) and spinal surgeries. UKR has seen the most transformation from conventional to robotic as national joint registry data shows significantly better survivorship for UKR performed using robotic means.

(Data from Australian National Joint Registry 2021)

Currently, there are many orthopaedic robots in the hugely competitive market. Some utilise image-based surgical planning, such as X-rays or Computed Tomography (CT) scans, while others offer imageless options that require the acquisition of intraoperative anatomical landmarks instead.

Most of the robots also integrate intraoperative soft tissue balancing feedback, and then under surgeon control, precise bone cuts are delivered, without the need for cumbersome jigs. In addition, some robots also provide a narrow operating boundary known as the haptic feedback zone, beyond which the cutting tool will switch off automatically. This feature not only enhances the precision of the bone cuts but also prevent the surgical tool from veering off into dangerous neurovascular territories, thereby providing another level of safety net to joint replacement surgeries.

3D printing coupled with robotics has also made complex hip and knee surgeries much simpler and faster, even negating the need for staged operations, bringing about significant cost savings and conveniences for patients. Presently, 3Dprinted implants are costly and difficult to get. Hopefully, the accessibility and affordability can be improved in the near future.

2. Which are a Few Technological Trends Influencing Orthopedic Today? What are Some of the Best Practices Businesses Should Adopt Today to Steer ahead of Competitors?

Three main trends are influencing orthopaedic surgeries today, namely:

I) Artificial Intelligence

Integrating Artificial Intelligence with orthopaedic robots will bring about the next revolution in robotic orthopaedic surgeries. Soon, automatic surgical planning and analysis of soft tissue tension will be the norm. With robotic technology and 3D printed implants, surgical planning and execution will be a breeze. There may also come a day when robotic joint replacements become fully autonomous. As surgeons, we will have to grapple with the fact that we may lose the human touch to robots. However, the possibility of a robot going rogue is not actually far-fetched if left to be fully autonomous; therefore, taking into medico-legal considerations, it remains how autonomous we as surgeons can allow robots to be.

Ii) Digital Wearables

Digital wearables collect patients ‘physiological and physical parameters pre-and post-operatively and contribute to a huge cloud database. Incorporating teleconsultation and tele[1]physiotherapy with digital wearables can propel the next wave of personalised medicine and data analysis. It can track pre[1]and post-operative outcomes and guide or refine treatment protocols according to real-time patient’s data.

Iii) Augmented Reality (AR)

Augmented Reality (AR) or virtual reality (VR) was previously thought to be confined to the gaming space, but now, with the pandemic restricting in-person training and surgical workshops, AR has emerged as an additional form of surgical training and intraoperative anatomical reference guide for orthopaedic trainees. Although the tactile feedback from current VR handsets is not as realistic as real orthopaedic power tools, the company that can bring about the most realistic hands-on training to orthopaedic trainees in future may be the ultimate beneficiary of budding future orthopaedic surgeons.

3. What According to You are Some of The Challenges Plaguing the Orthopedic Landscape, and How can they be Effectively Mitigated?

The promise of better outcomes using advanced technology does not come without a hefty price tag. Hopefully, as these technologies become more mainstream with better clinical results, the costs will also be substantially reduced to benefit more patients.

With digital wearables, patient confidentiality has to be mitigated with great caution to prevent misuse of patients’ medical information and the backlash accompanying that.

Moreover, every orthopaedic robot or augmented reality software is currently only tagged to a particular implant that the parent company is associated with, limiting their accessibility. It will be interesting to see a day when an orthopaedic robot or AR Software is compatible with any implants in the market.

4. Do you have Any Advice for Industry Veterans or Budding Entrepreneurs from the Orthopaedic Space?

My advice for industry veterans will be to embrace and employ these technological advances as they will only be mainstream in the near future. Budding entrepreneurs should focus on bringing the next level of orthopaedic technology that surgeons and patients can readily embrace, cost-effective yet precise, individualised, safe, durable joint replacements.