Dr Kreuzer and Intellijoint celebrate 2,000 cases with Intellijoint Navigation

Armen Bakirtzian (AB): So, Dr. Kreuzer, 2,000 cases with Intellijoint. Firstly, a heartfelt congratulations and thank you from our entire team at Intellijoint - it's a really exciting milestone to share with you. So, congratulations to start us off.

Dr. Stefan Kreuzer (SK): Thank you very much. It's been a great journey.

AB: I remember it was back in 2016 when we met for the first time and we were there in the first-time exhibitors area at Academy, and you are the reason that our company came to Houston. So, it's a really exciting milestone to be here with you today and to celebrate your 2,000^th case.  As a high-volume orthopaedic surgeon focusing on joint replacement surgery, some would say that a high volume surgeon does not need technology or navigation. So, I'm curious, why do you choose to use navigation in your cases?

SK: It's a good question. You know, people frequently say, ‘I don't need navigation to drive home’, right? But if you're downtown Houston, and it's traffic, I still put on Waze and click the home button, because that will tell me how to get home the most efficient way.

"I've always been a big fan of enabling technology. I feel like I'm a pretty good surgeon. But I'm not perfect, and if I can use some enabling technology, whether it's robotics, navigation, a sensor, artificial intelligence in the future, and I can do a better job, ever so slightly for my patients, then I will utilize that enabling technology."

View the rest of the transcript below:

AB: So the clinical research about the use of navigation has been, you know, some would say it's been inconclusive. So, why do you use it in your cases? Do you find that it helps you and it helps your patients?

SK: Yeah. So, one of my premises when I started doing orthopaedics is to try to really search what is the best place to put the implant? There is still lots of discussions, you know, is it 40/20 on the cup? Is it kinematic alignment versus mechanical alignment? So, for that reason, I always want to use some technology to help me guide that goal.

"I think it's under-appreciated - the importance of leg length and offset in hip replacement, which has been an afterthought; we've really focused a lot on cup position. And while an enabling technology, like Intellijoint, will help me place the cup in a better position. I like it more because it helps me reconstruct the offset and the leg length better. And I think that's important for function."

You know, we're investigating doing research studies with gait analysis to look at that to see whether it really makes a difference. But I think being more accurate is always better.

AB: And can you think of a particular case or a situation where a technology like Intellijoint has helped a patient have a better outcome?

SK: Yeah, we had a very interesting case, it was actually a Mako case done in an attorney in San Francisco. She had severe peri-trochanteric pain. And when you look at their x-ray clearly was an increase in offset. We then did a careful analysis with OPS. And sure enough, there were changes in all x, y, and z so the patient had three-millimeter increased leg length, had eight millimeters increase in offset, and more than 20 degrees increase in anteversion. And so really a femoral issue not an acetabular issue. We then ended up revising the patient, and used Intellijoint, and it really helped us try to figure out ‘how much have we changed the biomechanics of that hip?’. We were able to medialize the cup by about three millimeters, we reduced the head size by one length, which reduced our offset by three millimeters. And sure enough, the math was confirmed by the navigation system by Intellijoint, which really helped us to execute the plan that we had planned. And so it was a great case, we all felt very comfortable with our goal. And sure enough, the patient got better.

AB: Awesome. That's great to hear. And, of course, part of the value of navigation is having real-time quantifiable measurements in the operating room for you to make decisions with. Can you think of a situation where that type of information that has helped you or prevented you from making, say a sub optimal decision in the operating room?

SK: Yeah, so when we first teach how to do anterior approach hip replacement, we tell the surgeons you know you got to put the cup in about 40 degrees of inclination 20 degrees of anteversion so slightly above the level of the horizontal of the table. Well, there's been several cases where we didn't realize that the patient had severe pelvic tilt and an anterior tilt of maybe 15 or 20 degrees and had I used what I usually do, I would have severely increased the anteversion and the patient would have been unstable anteriorly. So, by knowing that the patient on the OR table had severe anterior pelvic tilt, I was able to bring my cup inserter much further down, essentially make it parallel to the horizontal, rather than what we usually teach. And so, it certainly helped me reduce errors, especially on the cup size, but also on the leg length side.

AB: That's great. And we’re sitting in your beautiful surgical facility at INOV8. Of course, you also operate in the hospital setting as well. What do you think about the portability of technology? And does it have a place in the hospital? Does it have a place in the ASC? And do you see it delivering different pieces of value for you in either setting?

SK: Yeah, that's a good question. Because we frequently get the question, you know, ‘how can you do robotics in a surgery center?’, because the reimbursement in the surgery center is much lower. And when we built INOV8 Surgical, we don't want to reduce care, we want to provide the same technology at the surgery center that we do in the hospital. Now hospitals have big purchasing powers, they have a completely different process of acquiring technology. But for us, it's not really been an issue, I mean we use Intellijoint in the surgery center, we use it in the hospital, we use robotics in the surgery center, we use robotics in the hospital. So, we don't really want to change what we provide for our patients and cost differently. The portability of Intellijoint makes it nice because we can move the computer from room to room the room so we can get away with maybe purchasing fewer instruments and therefore be more cost effective. And the device companies have realized that in the surgery center, you’ve got to be competitive on price because the reimbursement is lower. But we're not going to not use the technology, just because it's a surgery center.

AB: Great. Makes sense. And you just outlined a lot of different players, or options, in the technology space in orthopaedics. Of course, there's navigation, there's robotics, there's other types of technologies as well, you know, having done 2000 cases with Intellijoint over the last four years, why do you choose to use Intellijoint more frequently than, say, some other technologies that are available to you?

SK: Yeah, I mean, the main reason why I use Intellijoint is because I feel, and you know I’ve navigated with many systems, I feel it's accurate and it’s efficient. You don't want to do three-hour total hips. I was actually on the development team for Mako, and I enjoyed doing Mako hips, but the hip is actually a fairly simple joint. And so, I think you don't really need robotics for that. I think it's a good navigation tool. In fact, I get more out of Intellijoint navigation than I got out of the Mako navigation because it's more efficient, and it's just as accurate if not more so. So, while I like technology, I don't want to use technology that doesn't give me a benefit in the clinical outcome for my patients. And so, I feel very comfortable with using Intellijoint or navigation in hip replacement. On the knee side, I think there are some benefits of going down the path of robotics. Still to be determined with several platforms on the market. Still the clinical data is lacking to show its benefits to clinical outcome. The knee’s a much more complex joint. And I think really where robotics will play a role in the future is in if we really think on how we design implants. So, if we do resurfacing implants, or we do custom implants, where the margin of error has to be sub one millimeter sub one degree, I think that's where robotics will really hit it out of the ballpark. But in my opinion, no knee or hip replacement should be done without at least some measuring tool other than a caliper. So, I'm a big fan of navigation. Because it just makes me a better surgeon, makes me more accurate.

AB: Excellent. You've outlined why you're a big supporter and adopter of technology. Of course, you're not the only person in the operating room doing the surgery, you’re a part of a surgical team. How has your team, your surgical team, viewed the adoption of Intellijoint technology as part of your practice?

SK: Yeah, I think they love it. They are very much to the workflow. They know when to hand me what instrument. You know, it's a very intuitive software: You’ve got three buttons, the green button, the square button, the X button, and you don't even need anybody to run the computer. So, it's very intuitive. There're some people that will never get it - they'll always hit the wrong button - But you know, there's a little bit of a learning curve for some people, but you know, the younger chip heads they figure that out very quickly. So, my PA she can even do it without looking at the screen. She knows which button to play. So, it's very easily adoptable in the operating room. It's one tray. It's efficient. And that's really what, the end of the game is. And we actually have done a study where we show that with navigation, we are more efficient, quicker during surgery because it just kind of takes away the guesswork. So, you kind of have a goal, you go for the goal, you get it done, get the patient taken care of and we move on.

AB: Excellent. And I was going to ask you that question about speed and efficiency. Of course, you know, surgeons will say ‘I don't have time to add technology to my surgery’. So, you know, you kind of alluded to it just now that it makes you more efficient by eliminating some of the guesswork. Could you elaborate on how Intellijoint navigation makes you more efficient as a surgeon?"

SK: So, we did a consecutive study: we looked at a consecutive 300 cases without navigation and then a consecutive 300 cases with navigation. And we're actually five minutes faster with navigation. Which was surprising because the premise was that it was slower, but not to any significant degree. And so, what we can attribute that to is that the navigation takes out a little bit of the guesswork. So, if we can, if we know that, if we don't have to re-trial and re- x-ray and redo this and redo that in order to make sure that we're perfect- navigation kind of says okay, we're spot on, we'll move on. And so, from that standpoint, for us, it makes it time neutral, or even more efficient. Because the actual additional steps are maybe two to three minutes, max. Now there's a learning curve. And I always tell every surgeon you know ‘Do at least 10 before you give up on it’. And I think very few people that have done 10 navigated hips and have gotten used to interpreting the data will give up navigation.

AB: Agreed. And, you know, to that point about adoption in the marketplace and adoption of technology: of course, it's been a slower growth than I'm sure a lot of people would like, yourself and myself included, of course. So, what would you tell surgeons who have been resistant to the adoption of technology in their practice? What's in it for them? Why should they adopt it in your opinion?"

SK: Yeah, I mean, the game has really changed with social media. Patients are very vocal about their experience. And they're probably more vocal about their bad experience than their good experience. And probably one of the most frustrated patients is the one that has a leg longer than the other. They don't like it, especially in Texas, where women wear flip flops. If one leg is significantly longer than the other, they're miserable. And that in itself, I think is - from a selfish reason -  you should consider adopting technology, but at the end of the day, you know, we need to be good stewards of our patients, we need to do the best possible for our patients, they, they're totally asleep when we operate on them I mean, that's about as much trust as anybody can give you, right? I mean, it's, you know, you trust your wife, you trust your kids, you trust your mom.  But the patient, saying ‘Hey, I'm going to be sound asleep, and you got a knife in your hand.’ That's a huge amount of trust. And so, we shouldn't abuse that.  We should do the best we possibly can. And I say I never leave the operating room until I feel like it's about as perfect as possible. And if I miss a plane, so I miss a plane. I don't hurry through that. And, you know, one of the biggest compliments I got from [Intellijoint co-founder and CTO, Andre Hladio] once, he says ‘You know, you're the busiest surgeon I know, but you never seem like you're in a hurry.’ And I took that as a huge compliment, because we still try to do the best possible way we can. And I need information to do that and Intellijoint gives me that information.

AB: And last question for me: I think one of the reasons why, you know, technology hasn't been adopted in the past is, you know, it may take too long, it's the learning curve is too steep, maybe the workflow is intrusive. What are some of the features of Intellijoint in your opinion that make it easier to adopt versus maybe some of the more traditional technologies, or even new technologies that are on the market today?

SK: Yeah, the workflow is efficient, you know, we put two pins in the pelvis, we put a little disc on the greater trochanter. And again, there's a learning curve with everything, everything worth doing is learning - if it was easy, everybody would do it. And so, I always encourage surgeons to go through that learning curve, especially with Intellijoint because it's very efficient, the camera is inside the surgical field, you don't have to reposition it all the time. So that makes it more efficient. The tools are efficient. So, you guys have done a great job. Now I’ve started navigating knees now on some of the cases where robotics is not available. And that's been incredibly efficient. So, you guys have done a wonderful job doing that. Because data is important. Efficiency is important. It's got to be a happy medium. You know, I always want more data. So, I always tell you ‘Can I register more points?’ Contrary to most surgeons, who'd say ‘Hey, I want to register my three points and be done with it.’ So, there's a happy medium, right? So, if you continue to develop flexibility where certain surgeons can have a little bit more and other surgeons a little bit less. But you guys have done a great job making it efficient for us. So, that’s why I enjoy doing it and that's why I’ve done 2,000 cases.

AB: Thanks for your input for making us better and better and giving us the feedback to be better as individuals, as professionals, as a company, and as a technology provider as well. So, thank you for that.

SK: My pleasure.

AB: Anything else to add? Anything maybe I didn't cover?

SK: No, you know, it's a measuring tool. And orthopaedics is about measuring, and I always say ‘No Carpenter would cut a piece of wood without putting a ruler on it.’ Nor should I ever cut any patient’s tibia without putting a ruler on it. And so, you've provided that ruler for me and I appreciate it. Thank You.