American Academy of Orthopaedic Surgeons’ (AAOS) 2022 annual meeting convenes on March 22. The exhibit floor will be chock full of digital technologies. The market leader, arguably, is Stryker—whose MAKO brand of robotic assist devices has the largest installed base in orthopedics (excluding spine).

Stryker’s management presented 2021 sales performance to Wall Street’s analysts and investors last month. CEO Kevin Lobo disclosed that MAKO’s robotics sales jumped 27% in 2021 while knee and hip implant sales actually declined slightly between 2019 and 2021, Stryker’s hip and knee sales had declined from $3.198 billion to $3.190 billion.

Stryker’s installed base of MAKO systems is north of 1,500. Tops in orthopedics.

Impressively, more than 50% of all Stryker’s total knee arthroplasty surgeries in the final quarter of 2021 were performed using a MAKO platform. More than 25% of Stryker’s hip cases were also performed using MAKO.

Stryker’s experience is not unique. Sales of Zimmer’s ROSA system and Smith & Nephew’s NAVIO system, similarly, grew multiples faster than underlying implant or instrument sales.

Traditional orthopedics and spine product sales—implants, instruments, and their related products—grow at 3-6% annual rates. Digital products—robotics assist systems, navigation systems, augmented reality systems and advanced imaging systems—by contrast, are entering orthopedics at what appear to be breakneck speeds.

How do we come to understand these technologies and, more importantly, incorporate them into the treatment of musculoskeletal disease?

We asked Eric Timko, CEO of OrthAlign and former CEO of Blue Belt Technologies, which sold its robotic system to Smith & Nephew in 2016 for $275 million, for his analysis and outlook.

Timko’s OrthAlign recently announced Lantern, a smart intuitive, handheld navigation system for partial and total knee arthroplasty surgery. In total, under Timko, OrthAlign’s line of smart handheld navigation systems has been used in more than 250,000 arthroplasty cases globally.

We also include recent commentary from Eric Schmidt, former CEO of Google and from 2019 to 2021, chair of the National Security Commission on Artificial Intelligence.

But first, a quick reminder of the basic engine underlying this explosion of digital technologies in orthopedics and spine.

Figure 1 is a picture of the worlds most powerful computer chip with 2.6 trillion transistors. The second most powerful computer chip in the world is sitting next to it. It has 4.2 billion transistors.

What does this chip do?  It powers the artificial intelligence neural network software programs. Who is using it?  Argonne National Lab to accelerate cancer research. GlaxoSmithKline, AstraZeneca, and other pharmaceutical companies, large and small, to slash drug discovery times from decades to weeks!

Moore’s law postulates that the number of transistors in a dense integrated circuit will double every two years. And has been doing that since 1965. Your smart phone is smarter than the super computers of 20 years ago. And 20 years from now…well, we struggle to even imagine what technology will be capable of then.

Moore’s law is alive and well.

What is the future of digital technology?  We start with Eric Timko and some basic questions like:

OTW: Robotics, Navigation, Augmented Reality: What’s the difference?  How much functional overlap is there?

Eric Timko, CEO of OrthAlign, former CEO of robotics’ pioneer: Blue Belt Technologies: “When you think about these technologies, I think they match each other pretty well in terms of clinical outcomes, but the key differentiators will be economics and workflow efficiencies.

In terms of different types of digital systems for surgery, each, I think, can deliver better clinical outcomes than manual surgery, and there is an abundance of data to support that. We are seeing a mass movement from manual instrumentation to using some sort of digital technology. A lot of it is being driven by the larger marketing organizations at Stryker, Zimmer, DePuy, or Smith & Nephew, and patients are jumping on the bandwagon to demand technology as well.

I come from a robotics background, and I think robotics has had a significant impact on healthcare. The problem, though, is that robotics is increasingly inefficient particularly when compared to newer, smaller systems that bring huge processing power in a smaller package to the surgeon. The other issue is adaptability to every setting where orthopedic services are provided. There is a new technology battleground in orthopedics, the ambulatory surgery center (ASCs), with a totally different set of user needs.

When digital technologies can also improve efficiencies and lower costs, then I think we’ll see them being employed for every patient, in every room, whether at the downtown hospital or the ambulatory surgery center.

What we do at OrthAlign is hand-held navigation. Proven in over 250,000 cases, our easy to use, open platform is sleek, compact and all contained within the sterile field. The focus of our technology is to address the bulky and inefficient aspects of technologies like big box navigation and robotics that don’t fit well into the traditional operating rooms or ASC’s.

The place for robotics, I think, is where difficult patients are treated. Morbidly high BMI [body mass index], significant co-morbidities, severe deformities and so forth. But the mass market, your young, active straightforward total knee or total hip patients, who by the way benefit the most from computer assisted technology, the surgeon’s focus is to lock-in alignment, and hand-held navigation is the most efficient way to achieve those goals. In effect, it’s like the back-up camera on the car. It gives the surgeon the precise, objective information so they know exactly where they are so when they’re ready, they can lock it in.

If the patient is high-risk, then you surely want that protection of being in the hospital and using a big-box robotic platform. But we know that the best thing for a patient who is otherwise healthy is to get that knee or hip done, get up, get moving, get out and get home.

Every patient deserves advanced technology. That’s really what it gets down to.

OTW: Are robotics destined to be a standard of care?

Timko:   I truly believe that the use of technology in TJA [total joint arthroplasty] will be the standard of care, not necessarily robotics. The current healthcare environment can’t support that massive infrastructure of robotics at scale. It’s the space in the OR, the time required, the inefficiencies, the cost, and the need for multiple systems to support each implant.

Buyers, I think, are assessing every piece of the puzzle to make sure the technology best fits the needs of the provider in terms of optimizing outcomes, fitting into the surgery workflow, and being cost effective.

In terms of orthopedics, we’re just scratching the surface of digital technology potential. Where we’re going to be in 5 years, 10 years, 15 years…who knows, but one thing is certain: Technology is here, and it is here to stay.

Right now. Today. Every patient deserves a computer assisted total joint replacement. Matching the right care and technology for the patient that meets the operational and economic considerations of the site of service is where we are at. The more surgeons adopt accessible technologies, the faster we will move toward technology as the standard of care in total joints.

OTW: What could challenge robotics?

Timko: I’d like to answer that by going back to the early day of Blue Belt Technologies. When I first looked at it, I recognized that robotics for knee arthroplasty was a great indication, particularly for partial knees which are very, very difficult to do.

I recognized when looking at the Blue Belt robotics technology that, first, Blue Belt was doing robotics differently and, second, that the impact of a more user-friendly system on the surgeon as well as the patient would be profound.

When I looked at OrthAlign, I checked with the surgeons and asked them ‘Is this technology for the masses?’ Is this something everybody is going to embrace?  Everybody is going to say, ‘I have to have this.’ We are solving the simplicity challenge that comes with any technology implementation.

No way can big box robotics be a technology for the masses. Even if you put one robot into a facility, with seven or eight or nine operating rooms, you’re not going to write the check for seven, eight or nine robots.

But when a handheld navigation system can do hips, can do knees, can do unis, can do balancing, can do everything—and cost effectively fit into existing OR workflows—then every patient benefits, not just the few who can get to an academic center.

The promise of these digital technologies, I firmly believe, is to provide access to the best technologies to everybody: patients and surgeons regardless of setting, ASCs, independent clinics, or hospitals. As facilities work to build total joint programs that offer technology in every case, we strongly believe that those facilities that can address these needs through distributed handheld navigation will lead the way.

OTW: Artificial Intelligence (AI), is that a thing?  How will it enter and affect orthopedics?

Eric Schmidt, former CEO of Google and chair of the National Security Commission on Artificial Intelligence: You use AI today. Whenever you use Google Search, Google ads, spelling correction, Google translate. The story on AI is not really well understood. In the 1960s and ‘70s, AI was going ’going to happen within a decade.’ My friends who were AI obsessed, got their Ph.D.s in this area. And then everything stopped. AI stopped working. There was a period of about 20 years, which is known as the ‘AI winter,’ where the systems didn’t work. And then a series of mathematicians in the ‘80s and ‘90s invented what is today known as ‘deep learning.’

The important thing about ‘deep learning’ is that it allows the manipulation of patterns at scale that allow these algorithms to work. The big breakthrough was in 2011 with a process called ‘image net’ where there was a contest to see if computers could see better than humans.

Today, computers CAN see better than humans. Their vision is literally better. I didn’t realize at the time how important ‘sight’ was for everything. Cars should be driven by a computer. The doctor should use an AI system to examine you and then give his or her recommendations on your care.

I’d much rather have the computer look at my skin rash or the retina in my eye because we now know from many, many tests that humans make observational mistakes. The computers when properly trained don’t.

It was from this insight that you could do vision at scale that you began to be able to do prediction at scale. All of a sudden, now we are seeing systems that can predict the next ‘thing.’ Computers have gotten very good at predicting what will happen next.

OTW: In what ways does AI “predict”?

Schmidt: There are three events in the last three years that really are the index point.

GO is a game that humans have played for 2,500 years. It was thought to be incomputable. Not only did a computer solve the game, but it beat the top humans in both Korea and China. In that process, the computer invented some new moves and strategies that had not been known to humans for 2,500 years. That’s a big deal.

The next thing that happened was that at MIT a set of synthetic biologists and computer scientists did a very complicated trick involving going through 100 million different compounds and figuring out which compounds would create a reaction for antibiotic use. They came up with, using this technique, a new drug that could not be foreseen, which is called Halcyon, and it appears to be the next broadscale antibiotic. We haven’t had one in roughly 40 years.

The third thing that happened was that a group called Open AI built what are now called Universal Models where they read everything, they could find on the web into something they call GTP3, also known as a transformer, and all of a sudden, we have a computer that can speak what it knows.

OTW: What are the implications for medicine and, indeed, daily life of AI, GTP3 and pattern recognition at such a massive scale?

Schmidt: These models are interesting because you train them, and you don’t know what they know. And furthermore, they can’t tell you, you have to ask them. Many people think these universal models will profoundly change language and thought because they only get better with scale.

Five companies, a couple big ones and a couple start-ups, that are building what are called ‘trillion parameter’ models. These trillion parameter models cost $100 million or so to make.

That’s how exciting this new area is. You have strategy in the form of GO, you’ve got medicine in the form of Halcyon and now you’ve got language and learning models in the form of GTP3 and the Universal Model.

OTW:   How fast are these technologies developing and when will they be active in medicine?

Schmidt: We collectively believe that in the next 10 years this is going to come together and transform everything.

Thank you to both Eric Timko and Eric Schmidt.

Robin Young, Publisher of Orthopedics This Week.

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