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so if everyone would like to settle down and bring their metal platform up, So we've got a few poll questions to start with. I'm surely with Oliver. Should we go to, uh, pole questions? Um, Ignatius, one of the bowl to committee members this year, sets it as the Web edit er and a sub specialty interest in needs and research. So a few questions about robotics just to set the scene. If you'd like to start answering the questions and as the poll comes along and any of the Q and A questions, you can put it onto the chat and two more questions above as well. So do you currently carry out robotic navigation surgery in your unit? Do you have opportunities to carry out robotic navigation surgery in your region? And have you had formal training in robotics slash navigation? Mhm. An opportunity. It kind of means as well. If you are. If you have the opportunity to go to the private sector and learn about robotic or navigation, that includes that perfect. So it's about so it's about one in five for almost all the categories which will definitely need to improve on in terms of future work. Can we go to the slides, please? And for those of you who just entered the room, there are poor questions for you to answer to See if you've got any opportunities in robotic surgery. My name is Ignatius. I'm the current Web editors for Balta, uh, with a sub specialty interest in robotic surgery and research. So, as part of the innovation subgroup, um, there was there's an unless there's an identified, um, need for robotic surgery as it's come along. There wasn't any, um, trainee specific courses? No, nothing in the curriculum. So, as part of bolter, we went on to M S K radar as well as surgical solutions with health education England, and to try to push to put robotic surgery just like how arthroscopy was about 5, 40 30 years ago. And as part of that, we've, uh, some of you may have joined us in the innovation in orthopedics where there's loads of innovations in orthopedics, including robotic or navigation surgery. Um, but also something to address that by the time you're consultants, do you need a specific fellowship in robotic surgery or navigation? And as part of that we did a a partnered with industry to deliver the first robotic knee arthroplasty course. It was great fun. I don't know if we can play that video on the right. It was good fun. It was a cat of Eric. Day was completely cost neutral. Thanks to industry. Are we able to play the video? Please? Ignored tiktok video A walk around. We couldn't film the CATA very fit because of, uh, non disclosure as well as categoric work starting. All right, because But it also talks a lot about the nontechnical side of robotic surgery, such as getting it set up. Um, can your scrub nurses be able to keep up with you know that at the time, training within the department, your own training to get yourself up to speed. Um, and how many cases would then need to drop off instead of doing five joints? Do you have to do four joints or even three joints? Oh, so therefore, we've got a fantastic panel, uh, for robotic versus navigation. Uh, Frank would like to introduce them. Um, the poll questions will stay on, so just keep answering them. What is the future? We we don't know. Um what will be the future for robotic surgery who win with regards to robotic versus navigation. And we welcome anyone review to join us with Botha to see what we can deliver. Okay. Hi, everyone. I'm Frank, uh, current publicity officer. So we are into our chamber debate, and we will be debating robotic robotic assisted arthroplasty versus Navigated assisted arthroplasty. Um, it's my great pleasure to introduce our, um speakers for that session. Uh, Mr Ricky Plaster is a consultant in hip and knee surgery at University College London Hospital. He studied medicine in Manchester and finished his orthopedic training in 2018. He completed a fellowship in Vancouver before returning to London for fellowship in Arthroplasty and robotic surgery at U. C. L. H. He's a member of the Royal College of Surgeons trainee, robotic and Digital Assisted Surgery Group. Here's the trainee lead for the MSK, a robot assisted surgery group, and he's driving future training opportunities in robotic and digital surgery. Thank you very much for attending. And then we have Mr Jason Roberts. He's an orthopedic consultant at the Jubilee Hospital specializing in arthroplasty, including both computer navigation and, more recently, robotic assisted surgery He qualified in 1994 and training Lester Nottingham and the West of Scotland, including a one year fellowship in Grenoble. His first consultant job was in the Western Infirmary and Gardnerville Hospitals, where he enjoyed Acetabular fracture and pathological fracture fixation. He's always had a keen interest in sports medicine, especially due to his own background as a national level racing cyclist. And he has worked for Team Sky. Thank you very much for coming. So, uh, we will beginning with Mr Ricky Plaster. Who's going to tell us why Robotic assisted arthroplasty is the best. Okay, I have one. So in terms of going through, uh, navigated versus robotic arthroplasty surgery, I've been asked to look at robotic surgery. So I think we need to embrace this new technology I've given that idea of. We've had the jig based system simple telephone, and then we've gone onto navigated surgery, upgraded to a mobile phone, but not the best mobile phone possible. And now, I believe, with robotic surgery. It's more like the latest technology, and that natural progression seems to happen with technology and unfortunately, the NHS and in the health service in general, we don't seem to embrace it as much as we do in our normal lives. So why robotic surgery? Well, looking at Unsatisfied Patient's the main one is with knee replacements. We all know that hip replacements do better in outcomes, but at 10 to 20% of patient's that are just unhappy with their surgery, we need to try and improve what we're doing. And even if it's only marginal gains, we should be trying to do that with technology. So I'm going to focus on a few things there that you can see precision and accuracy survivorship, protecting your soft tissues when you're doing robotic surgery and then looking at the outcomes and potentially complex cases as well. We do need to talk about the elephant in the room, so the cost of the robot, the disposables for each case, how long it takes and the learning curve. These are all things that people criticize about robotics currently, and we'll try and look at those in a bit more detail. Is it all just type, So generally, with technology, you get this type of cycle so everyone gets a, uh, sort of inflated expectations of what it can achieve, and on the right there. You can see currently what people think about artificial intelligence. So we're now into the chat bots and autonomous vehicles. Um, and it all looks a bit doom and gloom, but there will be, uh, an uprise again, Um, as artificial intelligence changes the the way our lives, um, work. So we probably we've navigated surgery, and I'm sure educational disagree on this, but I think we're probably around the plateau of productivity. So we've we've got to the peak of where we can We've navigated, uh, surgery. And I actually think with robotics we're sort of at that peak of inflated expectation of what we can achieve with it. And that might start to be on the downturn. Unless we see some hard evidence soon with survivorship and things like that, which will go on to later. So what happened to navigator surgery? Navigation surgery. So, um, were we aiming at the wrong target? So if you see, there were the targets. Is it where we actually aiming for the right alignment in the knee, or were we aiming at the wrong point? We'll go into neutral alignment work versus new ideas now, and so was it just a case of If we had actually aimed at the right alignment for the patient, then navigation surgery would have would have performed better. There's also this human error. So you are still putting the bony landmarks, uh, with recognition of a probe. And so there can be human error there. It's not just down to the computer navigation also seem to be a lack of high quality research, the hassle of using the new technology in theaters and then a lack of industry support, which we probably don't see with robotics currently. So with the imprecision, you can see there with one study, there was quite a significant difference in the especially rotation of the femur. Um, and those those box plots show, uh, quite a few degrees of variation in where, where the surgeon was actually putting, uh, the media and femoral landmarks to work out your rotation on the femur. So you can imagine if if you actually went to a maximum era of 11 degrees or six degrees of internal rotation, you're potentially going to get major complications such as subluxation of the patella and mail tracking of the patella. So these were things that were probably seen even with navigated surgery and potentially with robotic surgery. We're not going to see as much of that so literature. There was a interesting study done here, a randomized controlled trial, somehow doing one side conventional on one side computer, navigated in 520 patient's. But you can see there. The survivorship over 10 years was almost identical, and there was no difference in outcomes. So the question that I thought with that is that you're actually performing the same operation. So people were still at that point, looking at neutral alignment or mechanical alignment, as some people call it, and just using the technology to perform exactly the same operation as you were doing with the Jig Bay system and potentially making the same mistakes as with the jig jig BAE Systems. So not giving the right, uh, rotation on the femur or the tibia and not looking at Corona alignment for the native alignment of the patient. And are we asking the wrong question? So we look at the outcome scores that we know there's potentially ceiling effects with Oxford knee score. Womack scores Uh, and so we're not actually looking at the patient's that are performing badly from knee replacement. And is that due to, for instance, alignment and other issues that we could improve on with this technology and probably the wrong patient's as well, the patient's that don't do well in terms of high demand and managing their expectations? Well, if you're doing computer navigated versus mechanical, uh, conventional alignment, is there an issue there that we've not quite picked out yet with the current research and that, and that's where high quality research comes into into play. So we now know that needs come in all different sizes. You can see there on the graph that the hip knee angle. So zero was neutral alignment, which everyone was aiming for with conventional jigs. And, uh, when navigated surgery started. That's what everyone was aiming for as well. Um, but actually, on average, in the mean people sit in slight various. But you can see there's actually a diverse range of alignment with severe valgus and various as well. And with that study there was 250 patient's that are a symptomatic and, uh, in terms of that that's basically pushed us into this idea of different alignment the're ease so you can see on the left there. That's the basic alignment theory that everyone started with. And that was due to the jig based system being able to, uh, provide you with a a simple solution of zero degrees. Um uh, cuts. And we've been been able to progress from that with the first of all, with big base system to kinematics alignment. Um, and now we can perform that much more precise and accurate with the navigated and robotic technology. There's also functional alignment, which is a new concept where we try and balance the soft tissue gaps You can see there with the MCO screen. You're trying to get the numbers the 20 millimeter and 19 millimeters balancing out, and that theoretically means that there's no overloading of the compartments either side and reverse kinematics alignment. That's that's a new theory. Um, like kinematics alignment. But you start with the tibia and uh rather than the femur. So with these new alignment, philosophies and ideas, there's kinematics alignment. A good study here from over 1000 patient's randomized to mechanical alignment or kinematics, and that actually showed better outcomes with uh, functional outcomes and a range of movement. So are we missing something with trying to restore the native mechanics of the knee? And, uh, is that Is that what's going to be the, uh, the next thing that we need to focus on so precision and accuracy is now possible, in my opinion, with robotic surgery. Whereas as we were just looking there with navigated surgery, there was still certain degrees of freedom because it's a human operator dependent. So we're now going towards robotic surgery where we can be a lot more precise with our measurements. But are we still inaccurate? That's what we still need to find out. Are we? Are we actually getting the right philosophy? Um, we're only going to find that out in in years to come where people are doing different types of philosophies and see who gets the better outcomes or whether it's kinematics or functional. So why robotic surgery? Well, the pre planning for me is the key change from navigated surgery, so we can now if if you have a free D based, uh, CT scan before you can actually plan exactly what implant you're going to use, which angles you're going to put on it and and carry out your philosophy. You then can go interruptive Lee and try and balance the gaps more and change your plan very slightly if you want to. But we've not been able to do that previously. So that report that Reproducibility is is now becoming possible. We've also got the potential of haptic boundaries, so protecting the soft tissue envelope and not using the sore blade that's going to be affecting that and damaging more soft tissues than you need to and can now focus on that soft tissue balancing because you can use your bony cups rather than extensive soft tissue releases some common issues of conventional uh, surgery. So we would regularly not regularly but sometimes see notching, and the risk with that would be a peri prosthetic fracture. Oversize in the femoral component is the opposite way, so you didn't want to notch, so you would then oversize it and over stuff the patella femoral joint and then obviously a type medial compartment. If you use a neutral alignment, you're going to overstuff the medial side, and then you need extensive soft tissue releases to balance the knee, so these are common things that we'd see. And I have to say, with robotic surgery, you just don't see those problems. As you can see from that plan the femoral component, you can just flex the implant as much as you want to get the smaller femoral component size on rather than notch. You can also look at the medial collateral fit and get the right size there and millimeter by millimeter decide how much bony cuts you want to make on the medial and lateral sides in all planes. So we sort of got rid of the problems with conventional, um, conventional jig based systems. And with that as well, we can also gap balance so we can start to look at these extension flexion gaps. And, uh, I don't know if you can play that video there. Yeah, um, so you can see it's balanced at 1919 millimeters And then, as you put stresses on, you can see whether it's tighter on one side than the other. Uh, and with that, the theory is that you can change the bony cuts to, uh, reduce the load. Uh um, and then you you can make the cuts. After that, Um, here's here's an example of us doing that. So there was a slightly tighter medial side gap. So we've increased the various, um, cut on the tibia to open up the medial gap and balanced the, uh, balance the gaps. 2. 22 millimeters. Okay, so that's an idea of functional alignment. And then you can recheck with the balancing, and you can see that the values have changed. So so that's that's a real benefit to robotic surgery in terms of survivorship. So we are starting to see some changes with a robotic surgery in the Australian registry as they've been the best at picking up robotic data. But if you look here this, this shows that we've computer navigated in the under 65 it's a similar result. But actually computer Navigated is performing slightly better than, uh, non navigated. But you can see there's a much higher, uh, revision rate in the higher demand. Patient's below 65. So what about robotic surgery? So they've only got data out to four years so far, but you can see in that under 65 group. The robotic surgery in the Green Line is actually lower, significantly lower than the non robotic assisted surgery. So there is that question of should we be looking at the higher younger patient's who are in demand for exercising and a high, higher demand lifestyle? Should we be considering robotic surgery for these patient's patient satisfaction? Well, actually, they all seem to do pretty pretty similar in terms of high satisfaction rates. You can see there the green is robotic computer navigated in the blue there, so we're not really seeing that difference in patient satisfaction that we were hoping. But is it due to this again that we talked about C leaning effect of patient reported outcomes? So there are new ideas about Should we be looking at the amount of activity patient's are doing? So are are they able to get back to exercise? Is that going to be a better outcome for the patient in the younger, high, higher demand patient? So it's probably going to have to improve our outcomes, collect collecting data to see if there's a some marginal gains from patient satisfaction with robotic surgery. The other thing is haptic boundaries, so the with the pre op CT plan, you create a free D model of the bone and that allows the robot to know exactly where the bone is and to cut out the robot. If there's a if there's a problem, so as as you're actually making so sore cuts with the robots, you can see the green is what what you need to cut. And there's a green fine line around the bone. If you if you actually push the robotic, uh, the robotic arm into that, the the sore cuts out so you can't create any further damage to the soft tissues. Uh, so with that, there's obviously going to be less soft tissue injury and, UH, paper by, uh, Kehlani and tell which showed reduced inflammatory markers over that first seven days because of loss less soft tissue injury. So you can see there in terms of into interleukins and, uh, TNF results are significantly different in over the 77 days. Also sure to hospital state, so three days versus four days after total knee replacement surgery. Obviously, within the NHS, there's a big drive for reducing the amount of Lantus stay of elective patient's, uh, as that will save money. So there is an element of saving. If if this is to be true, and we'll obviously see more of that with larger numbers that are now being performed in robotic surgery. And can we see that cost actually offset the price of robotic surgery in the future? There's definitely a possibility for that. It was a good paper on the Unicompartmental knee replacement in the B J J, where they looked at 200 robotic unit compartments or knee replacements. And they saw that, actually, if you're high volume center, um, your quality to get a quality of adjusted life years only 500 lbs and most of the treatments that are assessed in the NHS Uh, if it's below 20,000 lbs for for a quality adjusted life year, then it's deemed successful. So you can see that it's not actually wildly off, like everyone initially thinks, Um, and that margin is only going to come down as the robots get cheaper and we start to incorporate incorporate it more into practice. From just an anecdotal point of view. When you are performing unicompartmental surgery with the robotics, you get an X ray like that every time. There's never any doubt about what the X ray is going to look like. Whereas as I'm sure you've all seen, the, uh, with the Oxford, if your low volume surgeon or people are doing it, you will sometimes see X rays like this. That's not one that I've done, by the way, but that's just that's just one that I found. But you do sometimes see male rotation and problems with the cuts when you're using the jig based system on the unique, um, part mentals. And you just don't see that with robotic surgery, Um, which which is great and then just an added extra, which we're just starting to look at in terms of total hip arthroplasty of robotics. So the main thing, and probably the real benefit of it in hip replacement is for spinal disease, so that we're just starting to get the mechanics of the lumbosacral junction and how it works as a gear. And basically your sacred sacred slope works like a gear and closes down as you sit. And if you've got a stiff spine, this is a normal spinal changes, so if you look they're the sequel, Slope goes from 50 degrees to zero as you sit down. So if your spine is stiff you can see those angles don't change. So the sequel Slope stays open, and it means that you have to have two hyperflex your hips to sit down, put you at more risk of impingement and dislocation of the hips. So certainly with the literature there was a 7.5 risk, UH, 7.5 times risk of dislocation at 12 months if you have major spinal disease. And so is it a case of we're going to have to look at specific cases and complex cases where we use robotic surgery in total hip replacement? That's a possibility. Um, so it may have to be specialist centers that, uh, getting these patient's referred to make sure that we don't get dislocations. The pre op planning, As you can see there you get a nice X ray view of exactly what the implant's going to use on look like on CT with MCO, and you can even do virtual range of motion to check. And then and this is actually before you've even started the operation, and then you you can add on the inter operative data you can see there you can go through a full range of motion and see whether there's any bony impingement or if there's any implant impingement you can just see on the top right there. There is actually implant impingement in the red. So what we've done is increased the cup in inclination to 44 degrees and the version 2 22. And that's taken away that impingement. So it's a very nice thing to use, and we're starting to do more and more of that now with stiff spines. And it's just another case scenario so that this is a stiff spine and a 72 year old lady. Um, she's basically got what we call a stuck sitting position. So, uh, spine is tilted in a certain way, and it actually puts her at more risk of anterior dislocation. So you can see there the red at the back where the posterior osteophytes are. So those have been taken away, uh, to make sure that there's no impingement in the future. And then people talk about the learning curve as well. Well, actually, if you're trained in Arthroplasty, we've seen with papers that 7 to 15 cases is all you need to get up to speed and understand the system, and I actually believe it will be a future training model for trainees like yourself. Because once I started to do this training and use the robotic surgery, you understand the principles of arthroplasty even better. And if it's outside the operating theater, there's less stress, and you're able to actually focus more on the principles and what you're trying to achieve rather than be worried about the actual physical part of the surgery. So when you get into the operating theater, you're actually purely focused on that, and you've got all of the principles and the understanding there. So I think it will be an amazing educational tool going forward for everyone in Arthroplasty. And it's just cool. So that's that's just doing a uni. We're basically putting the stress on as though the cartilage was still there, and then on the right side is the graph. To show blue blue is, um, is loose and oranges tight, and so you can then change the femoral component and, uh, you'll see there that it basically changes that bar graph to make sure that your lax through our extension in flexion so just anteriorizing and proximal izing the femoral component. And then you get a nice balanced knee throughout the full range of movement. Yeah, so robotics over navigation? Well, the pre op planning for me is the real positive. It makes it much easier to look at exactly what you're doing. You've got the haptic boundaries potentially. If you've got that CT system and you can choose your alignment, Principal and Reproducibly perform that negatives are obviously the cost, and we're hoping that will come down. I'm sure it will. And the time added in theater, I think now, after doing many cases, it's only about 5 to 10 minutes extra. It really isn't that much at all. In summary, Hopefully, we don't end up like this with Skynet. But robotics, in my opinion, are the future. We have to embrace it technology to evolve and improve our practice. It might only be marginal gains each time, but that's that's what we have to do. The immediate future. I I do see it being potential search surgical hubs, looking at partials complex disease such as the spinal disease I was talking about and any severe deformity cases in young, high demand patient's um, and that's that's it. Well, it's going to be sort of hard to follow because I don't disagree with anything said so I'll give you a kind of my kind of more just fun stance of where we are now in the NHS. Okay, so I've been a consultant now for 16 years, and I was very lucky that my final year in training was spent in Grenoble and really, where navigation began in 1997. Um, and and, you know, I've I've been pretty much caught. You know, this technology and robotic technology for the future is the way forward. Um, unfortunately, first seven years in my consultant career, I had no access to it because the trust of us were, wouldn't pay for it, wasn't willing to pay for it. And then I eventually moved jobs to where I am now in a very high volume math past the unit where we do nearly 4000 joints a year 2000 joints, uh, 2000 and the replacements a year. And at least half of them are even navigated or robotic. Um, since I've returned to navigation, I'm immediately sort of seen an improvement in my own personal problems, which I think is always really interesting to see if you keep a very close eye on your own own data, and that's been very strong and helpful. And until very pertinent to this talk is I'm not paid by anybody to stand here and be here or anything like that. Part of my fellowship was paid for by Vascular, but that was pretty much it. I've done some training and teaching for them in the past, which has occasionally been been subsidized. But that's all I do know private work and that's my own choice. Got nothing against it at all. I'd just rather spend more time with my family and raising my bike. Okay, so these are the different systems that I've been involved in because we're in a center that's been lucky that the Scottish government have put a lot of money aside as an innovation center. Were one of the first few places to start using the Navio blue Belt and validating that. So we got some work with that and then thanks to sort of papers like fires paper, we managed to convince our board that we could buy a makeup and that was also helped in part in the Glasgow and Strathclyde University particularly, were very involved in the initial research with MCO um particularly looking at all the units by colleagues Stuart Bell and marked Live. Currently, I use MCO for all my Younis and I think it's incredibly consistent. And just as you've heard there that you know that you can get so much more from it. And I just never have to worry about my POSTOP X ray. And I'm already seeing a big difference in my 90 day return to follow up. We have a patient initiative follow up system now, and we just don't see the patient's coming in uncomfortable. And that in itself is already, you know, is already a key guide to why we should use the technology we have. Although I've been trained in mako hip, I'm not yet bought on it, mainly because in our you know, we've had a few patients having problems with the iliac crest trackers, and although I'm completely open to that technology and I think it could be really, really good for some of the very difficult cases, I just don't think it's mainstream enough for me to use it in my practice. So today I'm going to really talk about what I do with my total needs. Okay, so So why do we use technology at all? You know, as we've already been going through, We've initially started with mechanical access. We know that if we do mechanical alignment, we're going to have outliers. I had outliers in my first seven years of practice. It's that whole combination of a couple of errors. Wrong in the wrong direction. You're going to get an outlier, and that will lead to unhappy patient's. And there's good evidence to support that. What we don't know about knee replacement is exactly where it should be for that individual. So my philosophy from being in in Grenoble was that we tried to do as little soft tissue release as possible, and we tried to give every patient a very balanced knee that was as near to their pre morbid anatomy as possible, Really, and I think that's where the whole kinematics and functional alignment with knee replacement is going. You can't do that without a tool that's precise and accurate now completely agree that image lis tools are not as accurate as those following an image but at least they have the advantage that you can use them on every patient. You see. You don't have to send that patient for a CT scam, and you can get near equal results, which I'm hopefully going to talk to you about. Uh, bear with me a minute. This slide is a bit busy, but I've been on a really quite simple traffic light system, greens kind of goodish. Amber's neutral and and read the bad things so manually, there's no doubt about it. It's quick, it's cheap. I think we're pretty much stop there. I think with the image Lis robotics, we can be at least accurate in Corona and sagittal planes. We can have really quite a good feel of the soft tissues as well. And I'll talk to you how I do that personally myself. There is no doubt about it. With robotics, the pre op planning is the big thing. I've always preop planned and use long leg alignment views anyway for my standard mechanical and and navigated knees. But using the CT is just taking it to another level. So this is an example where I think, you know, I would always try and use somewhere some really good, um, image based platform and, uh, nice case where, Yes, I could use a navigation in the past. That's what I would have done. I would have found ways to put the pins around this metal work, but I couldn't be sure that I'd be avoiding this metal work without using a three dimensional scam. We're getting back to sort of my standard way of doing a knee. And I'll just take, uh, you know, kind of fairly straightforward case to begin with something we see every day high fixed flexion deformity with various knee. And in the past, it was a bit of guess. Ah, Mitory where you were, particularly the patient is a little on the large side. You've got no idea whether you've what the fixed flexion deformities, because you can't really feel where the bone is and you know, going back to manual techniques. You had to do an awful lot of in the head calculations to try and guess where it was best for that patient. And it's no wonder that you often ended up with a knee that wasn't happy. So my way forward is, I always do tibia. First I do it based on the long leg film, and trying to work out over that patient is a patient that's generally in various or in slight valgus. And I'll do my cut slightly accordingly. To that, I don't currently go more than plus minus three degrees from mechanical axis personally, Um, but maybe we'll do in the future when there's more good evidence to support it. Um, these tools here, my laminas spreaders are using every case. I actually even use it often with the makeup on my maker workflow when I'm using a navigated knee. When you couldn't see the workshop for B. Braun and and encourage you come and do that because it's a nice, simple, straightforward system, this is This is the kind of balancing page very similar to the MCO page, where you're doing the plan, and this is my plan Post tubule cut but pre femoral cut. And it means I can try and get as good a balance of the knee before doing any any major cuts on the femur, and I can try and balance the femur to almost to the tibia to give myself a really nice, well balanced me. I'll just go back on. Sorry. One thing I know on there you can see that there's a big red warning sign. They're saying that I'm gonna notch again. This is the kind of thing you're not going to be able to see very comfortably without some kind of guided technology. It's very simple in either the Meiko systems or or the nerve systems. I can just move forward and and flex my implant. It will slightly change the mid flexion stability. It will potentially increase the sorry decrease, the extension gap and tight money a little bit. So I might have to move around that for it. But at least on the balancing page, I can see that and plan for it. Okay. And that will give us a nice balanced knee. And considering I've done virtually no soft tissue releases beyond my standard medial parapatellar approach, we've got a pretty balanced need from quite tight deformity. So in my hands, I think this is probably where my stance is coming from currently with the navigation, I just don't see any errors. I've done just over 100 total knees now with MCO, and I said we we managed to convince our board to buy a mako based on on mainly the length of state paper. I have to say it hasn't been transformational for me, and we thought it might be. There's not been a huge difference in my early problems. Data didn't really expect that, to be honest, because if we look at our whole unit, we've got about 50% of the the consultants in the unit don't, um, use any form of technology over the manual knees and are early problems. Data is the same. It's just as a recap. We were saying It's you know it's not, you know, without doing gait analysis, some form of functional work that's way beyond what we have currently with problems. We're not going to see those improvements. I did unfortunately have similar complications, and one of my colleagues has had one major complication with the MCO in the unfortunately damage the extensive mechanism because you using the MCO and you'll see that later on the sawbones is actually quite difficult to get around the patella tendon. And although you've got haptic boundaries with the MCO the bit at the front of the knee, the robot doesn't know anything about, and that's completely up to you to keep an eye on. And I think people can almost forget that little bit when they're just following the MCO flow because it seems so intuitive and so easy just to push the sore where it wants to go. Pain. So that's it. In graphic details, it's really very similar. The only slight difference was a slight drop in, and we had a slightly reduced HB loss in the MCO group. This could because of the haptic boundaries. I'm not sure it wasn't it wasn't particularly significant. And with things like Tranexamic acid Now when you know we're just not transfusing anybody anyway, So you couldn't do anything beyond, uh, the actual basics. This is the big reason the big driver that I think why we should keep the navigation. It's the elephant in the room. Hardly any of the students are navigation versus robotics, and in fact, I can only find one really good study and I'll show you it later. It's always been manual versus robotic. We already knew that from the manual versus navigation. We know that navigation is accurate and precise. Okay, not maybe in rotation but certainly in Corona and sagittal planes. And we can remove our outliers, uh, Roger stickers. Work that was shown there with the arthroplasty data shows that when you get out to about 15 years, particularly the highly active patient's, you are starting to see differences that are significant. And he's now actually looking at the 20 year data from the Australian Joint Registry, and that's nearly 48,000 patient's. And they're starting to see that those curves are are going away from each other. So you know, technology can help you definitely reduce your and revision rate. And that's really a Holy Grail as well as improved function. Virtually all the papers people have incentives. Why they're there. The market's want us to go out and buy robots. Course they do. They've put a huge amount of money into research and development, you know, Striker alone paid 1.6 million when they acquired MCO in 2016. They've got to recoup that money so there is a bit of a hard sell and we were having a chat over coffee before that. I'm now actually starting to see patient's coming to me and saying or why can't I have this new fancy robot thing? I'm in N h f practice and I simply decide on one week clinic I put patient's down from now one week clinic. I put them down from MCO because I'm one of 14 surgeons. We only have three robots. You know, we can't do everybody navigated and you know, So I purely just have to say, I'm sorry. If you absolutely want a robot, you have to go and buy pay for it yourself and and that's going to become more and more ethically challenging. I think, um, and you know, currently, a lot of our efforts evidence is wrapped up in this conflict of interest. So some of the evidence that we're gonna probably go deep dive with Nick Clement later. We'll have a really good look and completely agree. There's lots of evidence that supports It's accurate, precise, and the fact that you've got an image based you are going to be the most precise with the MCO can't discount that at all. And the, um, it's easy to adopt. It's easy to train and learn. I'm a trainer. Over 50% of all the joints I do are always done by my trainee. Within a few cases, my training is doing it as well as me, if not better. There's no issue at all with it. The training of the theater staff can be a bit of an issue. Um, with the navigation it takes minutes put to put together and it's so mobile, it's easy to move between theaters. That's a great advantage. But even with MCO, you can very quickly teach your theater teams to do it or go and help yourself help them yourself. So there's no time lost between cases. These papers here are just just an illustration of what it's actually costing in real terms. And most of the papers that show this I think best are coming from Australia. And the reason for that is in Australia there's sort of, you know there's a big adoption of of navigation. 32% of Australian surgeons are navigating in 19 in 2019, I believe in 2022. That's up to 20% of them now using robotics. They're not paying any more for it for most patient's. So that's why a lot of their papers are quite useful So this is one the one good trial that I can find and from Sydney between navigation and robotics. And although there was a small a small number, they were only doing about 78 robotics a year, and there is definitely an increased volume going to see some advantage with it. If you do in a small unit that's not doing big volume, you're going to be paying 2 to $3000. They're more per case, and I just don't think the NHS can justify that right now. This is a nice paper below by again, the guys from Western Australia that really go into all this in great detail. And it's also a really great literature review finished with this very nice little study. Eloquent study from sort of bars, Masri's group in Vancouver, where they did a nice simulation looking at lots of comorbidities, Um, and just trying to find if they could do an RCT between navigation and computer robotics to see if there was a true difference in revision rate as the endpoint, and they decided that you need at least 4000 people in each arm to show any difference at all. So That's the kind of numbers you're gonna need to treat to show an improvement from robotics over navigation. So definitely, I think technology is a massive advantage in joint replacement. But let's not forget navigation yet. It's 25 year old proven technology that is very cheap compared to robotics. And although I think robotics probably is the future, then you know we're looking at now. And in this current economic climate, I just don't think robotics is quite there yet. Thank you. That's an excellent summary between robotic and navigations. Can we put the pole up, please, between robotic navigation? So while we're doing that, we've got to do to time. We're gonna answer two of the most voted questions. Can you can choose neither or both. So, um, we pick these questions that we think they're really important. Um, the first is from Francesca Solari, and I think it's a really important question, not only from a trainee's perspective but also from a patient perspective, uh, in terms of inequality of access to robotics and navigator surgery. So, she says, how can we ensure access to robotic arthroplasty for trainee so that training opportunities aren't dependent on your geography in the UK. Yeah, I'll take that initially. It's a very difficult one to answer. Really, Because we've got this massive issue currently in Scotland in the Our unit is currently the only NHS unit that has access to robots. And not surprisingly, the local TPD is getting inundated with people saying, Well, I want to come to to your unit to train and we only have two trainees every six months of the West of Scotland rotation. So it's a It's a massive issue. Um, as as more units get robots, then yes, it will be possible. From the navigation point of view, we have at least seven centers just in the west of Scotland that have navigation options. So at least you can get a start with advanced technologies in those units and the difference between in my hands between navigation and robotics. Actually, once you you know, a navigator, the move to robotics is really, really straightforward. Yeah, I'd agree in terms of the learning curve as well as we were talking about. It is very small when you already know the techniques. We're not actually changing the surgical techniques drastically at all. So, um, I think it will still be general arthroplasty training, learning the principles that way but potentially like I was saying, out of theater training with robotics and, uh, courses and workshops will become much more common common place. Our next question follows quite nicely after after the first question and the explanations from Runway and he asked, should trainees be fully trained in conventional arthroplasty techniques prior to being trained on robotic arthroplasty techniques? Yeah, I think, like you say ties in nicely with the previous question. I think realistically, in the NHS, it will go that way. So you will have your, uh, conventional arthroplasty training first and and then, depending on what center you're going to working or what the availability is, then you'll have a either a short term fellowship or during your training you will sign up to robotic courses and workshops, uh, to gain that experience. But if you have that underlying training of arthroplasty, we just see a very quick transition to as as you're saying, the trainees pick it up so quickly. Um, so, yeah, it doesn't seem to be a problem at all. Okay, we are running a little bit behind on time So, unfortunately, we've had to restrict it to two questions. Um, Ignatius will talk to you about the sessions with the robots in the afternoon, and then we will introduce our next part of the schedule. It's great to see that most people have voted for both. So if you have the luxury of having two types of technology on the shelf, that's amazing. Um, and maybe you can talk to industry. The most important thing about today is to try to engage with industry and the robotic session this afternoon. Just as you know, if if you go on the program, um, we're going to break into three groups. One will be striker MCO. One would be be round Rosa, and one will be may call principles in alignment. So any specific questions go to their that is restricted to 30 delegates each. So get there early, get lunch. And then, um, we'll see you there so it will be 2 to 5 o'clock. May go. And Rosa needs to leave ASAP to another meeting soon. So we're restricted to 45 minutes. Oliver Will Oliver will bring one group, um, run Will runway will bring one group and I will bring one group so 30 delegates each. Any questions? If you are interested in in a session, they're all in the album. Sweet, just out on the back corridor. So at two o'clock, can you start making the way there? And then we'll direct you 34 and five. And if anyone's interested, this, uh, autopilot navigation and VR is also available in meeting one. So there's loads of things going on at the same time, Thank you very much to our panel for inspiring the next generation of robotic and navigation surgeons.