Dr. Florian Gebhard from Ulm University in Germany discusses Polytrauma and the Inflammatory Response as well as his 25-year experience in Image Guided Surgery.
All right we’ll go ahead and get started couple people sit down so I’d like to thank everybody for joining us for the David Kaylor uh visiting Professor lecture and drama um start by saying a few things about Dave Kaylor he was um important part of my starting practice uh was very generous
With his time um and with his experience uh thank Vicki for joining us his wife uh we talked at dinner last night about the the cost and expense of experience sometimes when you have to gain all of it firsthand so I’m certainly appreciative of Dave sharing
That um and saving me some some of that pain um but could tell stories about him all morning what he meant or means to me uh both personally and then within Orthopedic Trauma uh but that’s probably appropriate for some other more social setting um I’d like to introduce our
Trauma visiting Professor Dr Florian ghard he has more accolades than I could reasonably list but uh foremost of those he’s the director of the orthopedic Department uh at the University of ol and is our immediate past president of AO having served from 2021 to 2023 he is a talented surgeon researcher
Educator um and and I think one of the common ties that he has with Dave Kaylor is he’s really been at the Forefront of introducing technology into the operating room uh to improve techniques and outcomes so thanks in large part to Dave I was able to spend some time in m a
Little over a decade ago so that’s a little bit of a tough pill to swallow time goes by quickly uh and see their futuristic o firsthand we’re going to learn about that some this morning so it goes without saying I feel a huge sense of gratitude for that experience and
Know that we’re very lucky to have Dr Gart here with us today uh appreciate him making the trip from Germany wasn’t excessively complicated wasn’t perfectly smooth but uh still great of you to do that and uh spend time with us visiting uh seeing Charlottesville and and the lectures
Today um Dr Gart was always the first choice that Dave Kaylor would bring up as somebody who we just have to talk him into to com to UVA he uh I think had a lot of admiration for him um and and I couldn’t agree more that he’s a perfect
Fit for the Dave Kaylor visiting Professor I know he’d be proud to have you here uh we’re excited to hear your lectures like to invite you to the podium Dr floring Gart well good morning thanks space for the kind words V good morning good to see you again and good morning everybody
And I’m really honored feel privilege to be here because it was one of my bucket list someday visiting this University and I really enjoyed today yesterday so uh um for today I’ve got two talks to you one is about so my department has two major research areas one is basic
Trauma research that’s the first one I assume it’s more the dry one then you go to computerist technology that’s a little bit more entertaining and this will be the second talk so um said um the department a little bit comparable to the size you have here in
Uva um we are level one Trauma Center recoveries we have C area 1.5 million people we have two major highways that’s excellent for drama so we are are very busy unit and um okay one flashing red and green no it’s green better oh okay so uh but I don’t repeat
What I just said so okay first part is about poly trauma management and this one does not work now so I press it here and first thing is just who is this male gray person here old as well so I’m Munich born and raised yesterday I was asked about my f
Famous soccer club it’s Bayern Munich of course um and so this is a very traditional old city that’s a royal gymnasium I visited and that’s the Munich University we have two in Munich one is the LMU That’s the older one that’s this one I attended um then my
Training started with the Army uh and I had a well not so bad time spending my time and you have seen even those days it’s quite a long time ago we had a female part that supported us in the hospital then I had got some deployments
One of the most interesting one was a un mission in Somalia you can see that here um and I got the cover face of a UN book so that was my first career step I I love that um and this is the town I’m working now that’s the highest judge
Tower of the world still um on the bottom line the green that’s the denu river which is one of the largest river of Europe and then what I like most you can see the mountains in the distance it looks like very close in real it’s an hour drive uh but living there and
Working there is quite a lot of fun that that’s about the size of the department on top you can see that’s the old building and now this is what this are mentioned that’s the new surgery which has been opened in 2012 and this construction is really fits to
Traumacare so inside it’s a very functional um system on the right side you can see this um high-end o room uh which I will talk in my second talk about these are my hobbies so my wife does not agree with everything but um it’s fine
So what what is the rational to do poly trauma research okay so there are statistics and you can see that road traffic injuries they really get up the letter so it’s top five now globally um and today because of the um Global development of conflicts even a new type
Of trauma is increasing in numbers and if you calculate this globy that’s a huge clinic and socioeconomic challenge because it’s always the young ones that get injured and so these are the ones who are supposed to work and contribute to um economics uh and so it
Makes sense to take care um for those uh who are injured in this uh age time and so you will see now a few busy slides but just give you the impression what is happening if you look for trauma research so on the right side you can see any trauma triggers a dangerous
Response in the body and this is a systemic disease it’s not a local femur fracture or a forearm fracture it’s a systemic reaction that starts in any kind of trauma simple fracture to multiple injuries and then within the body you have two lines one is inflammation protecting the body at the
Same time regeneration starts and this is always the balance between both processes whether you have a good outcome or a bad outcome and this starts at the very beginning and you can see here on the left side a lot of uh systems of the body trigger this inflammatory response and the most
Important one which we could demonstrate is uh tcic trauma com and the combination with total brain inj uh bra uh brain injury and sofish injury and this is the one who um are the most important uh things that happen then you can see here there are a lot of signaling starting at the
Beginning and at the first 24 hours it’s the hemorrhagic shock that threatens the body and it’s uh triggered by the Cathy and all these pathways are the most important ones in the first 24 hours um and then it’s very important that within the first 24 hours the body gets the
Balance between Pro and anti-inflammation processes otherwise the process of tissue repair will not start adequately and um will have a not so good outcome in the patient and what we are doing since now more than 20 years that we have a look at the total body as a responder to um
Any trauma so it’s the whole organism that’s in danger and we looking about the processes um that are triggered by trauma is uh the end point what’s the outcome quality of life at the end of the day and the response is in different levels so you have uh fluid cells
Organisms and the whole body and within that there are different pathog mechanisms that are started at the beginning and the only thing what we can do the first 24 hours because we cannot redo the uh the the trauma we can try to help the body to get stabilized between Pro and anti-inflammatory
Response and um so what we are doing we have a research group uh which is like 60 people working on that one in different uh uh uh groups and they look at all these different aspects of trauma because if you’re getting a little bit older then comorbidities like um osteoporosis
Diabetes or Parkinson’s disease all these neurological disease they are called disturbance factors because if you get injured and you have some comorbidities they will trigger a totally different response to trauma compared to a young person that has no comorbidities and if you take this into account you you see that’s a very
Complex topic and like 25 or 30 years ago when I started to do this research there was every second month a paper called the Magic Bullet in trauma and everybody proposed a new parameter that’s the one you need to trigger like TF and Alpha was one of the first ones
They even did a antidote to tnf Alpha and then well what happened many patient died more than the prediction was because they blocked the antibody and this is the and then science learned that it’s always a pro and con and if you block the pro then con gets too much
And some of the pro-inflammatory um parameters also are helpful on the long run so it’s a big pot of soup and if you take a spoon of out of that all the ingredients are in that one and you can’t decide which is the most important one in this type of soup and
So that’s the challenge and maybe so that other bus work today is AI maybe AI can help in the future to sort out all these uh this idea uh this parameters which are currently um on the market as to say but if you do research in that
One you can’t do this on uh on patients and so what the beginning we set up a a model system for trauma and this trauma is the model is the mouse because uh mice you are available as a knockout mice a something deficit M and it’s a
Very nice tool to mimic some sort of injuries or comorbidities and then we created a mouse ICU so we can take these injured animals on an ICU they got you can see that they get a nerve monitoring using micro electrodes we uh um get um Rous lines in the mice or arterial line
We inflate them so we can um Breeze them for 24 hours and we have Imaging you can see that we have a MRI meanwhile we have a pet MRI where we can do a lot of Imaging in these um injured animals and after that we go into uh into the bench and take
Histology and make cyto profiling all these things and by that one we can mimic what you can see in the lower end a real ICU but with a defined trauma and a repeatable trauma um and this comes very close to the to the real world and
So if you do this for a long time time there are a lot of fun facts behind that you don’t have to know about these parameters so these are U mediators of the brain but what you can see here of the readout is if you drink some alcohol
You protect your brain so um doesn’t make sense to drive drunk now but obviously um ethanol has some protective effects on the brain so people and we check this in patient who had a little elevated ethanol level um they behaved different and we tested this in our
Animals and they did the same so that’s nobody would have expected we are working on that so currently this group Works what’s the best amount to drink before you get injured um so but they I can’t give you the result to that one yeah the other one is that if you are
Stressed at the moment when you have the injury your body behaves different how can can you test that what we do um we do an early maternal separation so the the new uh born mes are separate from the mother and this puts them on a stress and then you can uh create a
Non-stressed and a stressed mouth and they behave totally different and the stressed Mouse has an impaired bone healing for example uh you can do it the same uh setting um is a psychological testing if you have an old male Mouse and put in a young male Mouse in the
Same box then young gets stressed very quickly and if you do this for 24 hours you have a adult Mouse that’s also totally stressed and if you then take them to the um experiment they show that um they have a different inflammatory response and an impaired bone
Healing for clinics what is the the read out of that one depending on the situation you get injured your body body will react differently saying you’re driving totally relaxed and something happens then you are not stressed but if you’re like um um someone who is in action like U policeman or a fire
Brigade officer and if they get injured they behave different because they are stressed because they are in action and at the long run we don’t know out of these findings whether this is a significant impairment of the bone healing but there is an impairment which should be considered when treating these
Patients on the lung run and then the other thing is so if you have a multiple injury and I told you chest trauma is a very important one you would assume that this patient has um issues with healing but interesting enough another fun fact if you got a a chest injury your wound
Will heal quicker so the reason is not known but it’s a significant increased wound healing capability of uh the experiment where they got a chest injury if you have survived injury the quality of regeneration that’s bone Heating and regeneration of damaged tissue is also an issue and for that one
We use zebra fishes so this is one species if you cut um the the the back part it will regenerate within a few days yeah and by doing that and these are little filaments you can see on the upper left and if you cut them then you
Can see what type of cell reaction is needed to make a regeneration of the bone skeleton of these fishes and this is an interesting part of our research and these fishes get U mediators um which we get out of our experiments from demisis and then we can see whether the
Regeneration um is uh changed in these uh in these species this is uh work ongoing but what we can see currently that we can mimic the bone healing in a zebra fish and can see what the zra fish has different mediators during regeneration what we are lacking so well
In the long run maybe we find something you inject and then you regenerate the L uh um or amputated extremity but I think that takes more than 10 years okay so based on these um laboratory experimental findings we have a very straightforward setting how to treat uh multiple intient I mentioned
This so these are the killing factors and then we have some deadly combinations if you have a chest injury and a pelvic injury usually you have H in this combination or if a TBI and abdominal which is also Hemorrhage injury that’s the worst you can get because then you get an inflammatory
Response that really um endangers the whole body and So based on that one we really believe in a second hit Theory um and one of our parameters is I 6 we discussed it yesterday on the hike um this is one of the parameters we rely on uh because it
Starts very it’s very unspecific you can’t read out that if you have a high I six that that’s exactly happen in the body but you can say if I6 is increasing rising up there is something wrong and you have to take care about that if it
Uh is uh falling down then there is a clear recovery and il6 is one of the very very early pro-inflammatory mediators uh so it makes sense to look at that one and so in Germany we have a lot of Airbase rescue system so usually the time from the side of exit to our
Emergency room is less than one hour and then then we give us one hour for the work around in emergency room before the patient goes into the or or into the um ICU unit and so this is also to say the side of the accident and I will show you
Some data where we took the first Blood probe at the side of the accident because in Germany there’s always I am MD on the helicopter so and if you just convince them that’s worthwhile to do that they will get blood probes at the side of accident and all these
Parameters are immediately out and usually so the average time between something happens during daytime and the first respond is on the side this like 12 to 15 minutes in in our area so that means that within 10 minutes or 50 minutes latest all these parameters are regulated but the whole set of
Inflammation is already there at the side of the excident and then you can see at this very early data where we start this research a that’s the side of the accident H is hospital and you can see all parameters are already elevated not very high but they are elevated so are
In place but then you can see that so the time between side of accident hospital I told you it’s roughly between 30 and 45 minutes you can see exceeding level of il6 and then the top level of il6 um is the ones who have the severest
Injury so that’s the ISS more than 32 patients and there’s a clear correlation between survivors and nons survivors so if you take the il6 is an early parameter and this patient has a high rise in the il6 he does not drop down before following day then there is a
Strong likelihood that um he will not survive whereas all the other patients you can see they will drop down between day two and day six latest and that’s the window okay as soon as you can see that I six drops down this patient will recover and you can use this window for
Doing uh surgery um we have a very strict system typically German which is given by our trauma Society um and Define what you need an emergency room and a little bit different to your system the trauma surgeon is the leader so we if you are on call we go to the
Emergency room and see any kind of trauma firsthand together with the anesthesist and it’s a big struggle between us and anesthesia who is the leader but so far we are the leader but sometimes anesthesia claims that they are better than us uh but as long as you
Do the research you have a lot of information that the UN anesis does not have and then you can challenge him with a few parameters and you say okay okay I go on and then on the left side that’s the basic team that’s always available if emergency comes in and then we have
The extended team um which are have a notification time of half an hour to be in the emergency room and then there’s a clear setting sorry it’s in German but to translate this takes too much time but you can see in the center is the patient and then everybody has a fixed
Position where he should do his work and this will be trained so even if the if you got the full full emergency team with all these specialities everybody has a clear area where he can do and the aim of this setting is uh first of all
Education second to make it as quick as possible that all these procedures are done uh in a time frame and I told you the time frame is 1 hour and this is written down in a textbook it’s available in English as well and it’s updated on a regular base and this is
The recommendation of the our trauma Society how to take care in emergency room yeah and these are then all these algorithms we follow and you can see there’s always a timeline on the left side to 10 minutes that’s what has to be done in the first 10 minutes and we
Always start a clock that runs on the wall and gives us the time and this has the colors so there’s a Red Zone yellow Zone in the green zone and everybody of the team can check are we in time or are we uh late everything is on the register
And then you get your feedback that’s your hospital that’s the other ones that do better and so that’s a system where we can um challenge each other and um and it makes sense so we have a really good workaround um for the emergency room and it’s working together
And if you train that it’s helpful for the patient and then so um we are all atls trained so there’s no difference in Germany that’s that’s how we do that um and so key issues are that we would like to have a fast scan within five minutes usually it’s done by the
Surgeon um the radiologist comes in later um chest x-ray is still written down within the first 15 minutes but meanwhile everybody gets a whole body scan and so we just uh leave the ch xray um except the anesthesist wants to see where the tube is about the uh if he
Has some troubles with uh um inflating the patient otherwise this we can Skip and then we do this um very quick uh total body scans and I think that was really a step forward because within a few minutes you get everything what the patient um has got injured and then
Maybe most of you have heard about crystal pipe he was in Pittsburgh for several years then he went back now he’s in syk but originally is a German and he made this stable borderline unstable classification of patients uh which I think is really valid uh globally and if
You follow these lines then you can sort your patients in this um degrees of stability and decide whether you go to the o or you do damage an early Total Care you do the damage control you just say okay no this patient has to go first to the ICU but all this clinical
Recommendation is based on the research data I showed you at the beginning so this is not just experience but it’s really proven by um animal experiments and so this is what our policy we follow this uh recommendation so we do at day one if the patient is
Okay as much as possible and we do all the things which are needed immediately but then we give us a limit together with the an anesthesis say okay this patient can have surgery for four hours or six hours but then he will cool out or he has to
Go to the ICU um then we stop that and then we wait then we monitor this is6 what happens does it turn around and uh Decline and then we go for a second time of surgery usually at day four day five um I know that’s two sides okay that a
Transatlantic disc since many many years about um early Total Care and damage control Orthopedics I think the truth is something in between and if you take the individual patient and decide for the patient patient then you will do a very good thing for the patient and will not
Harm him so there will be patients you can do everything on the first day but so we we usually see uh look for the agreement with the anesthesis and say okay you check blood clotting the disorders and all these things during our surgery and if you feel this patient
Goes wrong way then we will uh shorten our surgical time um so the choice is somewhere in between but it works quite nicely and for example this is the motor vehicle accident um got the trauma scan um had a spine injury had a lung injury
And lung injury as I told you we believe that’s really one of the the game changers if there’s a lung injury be careful because that triggers a lot of inflamation um that’s not very good for the patient um and then he was this type of pelvic surgery which is not that
Spectacular as I’ve seen yesterday night just a very simple frct and we don’t treat that immediately he gets an external fixator for the femur um then day five he gets the final stabilization and this is the type what we do nowadays with these minimally displaced fractures that’s computer assisted screw doing um
And this will be part of my my second talk and 6 months down to nine this is uh more or less okay um and so based on what we find in the mice setting in our mice ICU and Trauma setting we are totally believer of the second hit
Theory um and you have to know that this information is invisible it’s just you can read your basic data and say okay I know that a mouse reacts like that one this patient will do almost the same so be careful look at these uh key injury like brain injury uh thoracic injury
Severe Hemorrhage because these are the triggers for um blood clotting disorders and um all these increased inflammatory response and then we treat on the based on this injury pattern as an early Total Care or damage control Al Pedic and this implicates that you you do an early identification of these patients
At risk as I mentioned um if you have got this combination then we are super super uh careful doing not too much uh which is not really needed at the first day um and by that one we always tell our people you’re not a bone fixer but
Uh you’re the one who stabilizes the patient and helps to resuscitate the whole organism um to get the best um recovery out um of an injury and so this is our philosophy and um we running we have U an an aate 300 of these um ISS
More than 16 patients per year so we have a sound um experience in doing that so thank you very much this was the dry poly trauma story any any questions to then it’s dry I know when you are uh you have a separate team in the ICU that is managing the
Patients TR surgeons aren’t the ones you’re handling it from the ER but you’re not actually handling ICU no uh we talked about6 is there a sort of a objective discussion or is a combination of subjective and objective when you’re talking about the patients stabilizing for the next part of the
Surgery trending down but maybe they’re still on a lot of pressure agents or you know maybe they have an ICP monitor that’s kind of a little bit unstable are there is it a you have clear criteria or is it is there some a lot of discussion
And talk and say well maybe not today maybe tomorrow because of this yeah so it’s a combination of both so we have clear criteria we want to see that all these scores go down or improve I6 should go down um but if the patient behaves totally different what the lab
Findings are then we have to discuss this with our anesthesia or Intensive Care Partners and uh the big point is always uh neurosurgery because they tell you well the brain will swell if you do that tomorrow and I can’t see a brain swelling and I can’t predict that so
This is the most challenging part to get the clearance in a total brain injury that you can do surgery but usually so our um ICU people are interested to get patient as quick as possible out of the area so they are interested that we do this surgery as early as possible so
Sometimes is they push us to do surgery and we say no wait a day or something like that so it’s a fair discussion and it’s both it’s patient the individual and our lab findings and is your discussion also well we’re going to do perania surgery so we can you’ll have a
Discussion about the length surgery at the time and I noticed you plated that femur fracture that you were showing nor that might get a nail but was that a lung injury thing was Thats So the one who did that decided that an M procedure this was the M
Played uh is as good as itn’t no so I know this it’s the other discussion and separate talk about nailing and lung injury but usually if so this um patient is good in within 24 hours for nailing or 48 hours that’s not an issue um well less reaming maybe then
And a smaller nail but that that would work okay sounds like the down arrow might now to advance that want try to use the let me down maybe I should open the box here see other good Lessons Learned yeah the button okay now uh more interesting part
So this is what I like most in my daily practice doing a computer assist surgery and so it develop is like 30 years so in the mid 90s um this type of surgery was introduced first time for spine one of the uh big names is L NTI from Burn they
He introduced this navigation tool to spinal surgery but in the ’90s the ORS looked like that one in in our setting and the hospital was on the lower left this was the old 100y old surgical department and this new technology did not really fit into our o rooms as you
Can and see here but we were lucky in 2012 to open the new building and then we were first time we were able to integrate this technology beforehand and that really uh fits quite nicely and so this is a little bit of a journey about how these technology develop and this
Was in the end of the 90s this was the system we got it was called Med Vision system uh it was a Swiss engineering product so very solid and you could do almost everything with that and they had strange things like a digital touch pad
And a special tool to touch on this one um and but from the it looked not bad the camera was huge you can see that if you take that in your room there’s little space left where you can do any type of surgery so at the beginning so
This was a lot of stuff you had to just take somewhere in the a room and then right side you can see every single instrument has a cable as a power supply and handle cables in a surgical field being sterile was really not the way to do that but anyway we were convinced
That’s a good technology and we stayed with that technology then we had some strange things like gravity I don’t know until today why we KN had to use gravity should be around the globe the same but you had to have this gravity tool otherwise maybe there’s some bending in
The camera side or whatsoever so it was really highend technology but we used uh we were able to track our CMS at that time it was the iso one of the first ones and that you get the coverage there were LEDs in it um and so the navigation
System could track um that and at that time that’s the lower right on the left side that was my boss at that time and he said you do that so it was always the same he was looking at the camera or at the computer and say okay what are you
Doing here and I was the other side just doing something and then after half an hour he said but stop that I do it now and a standard procedure so this was happened very often at the beginning but by time it got better at that time you
Had a pre Optive CT scan and then the challenge was how to match the data set with your patient intraoperatively yeah and one of the um things in spine surgery what we learned very quickly your primary CT scan of the spine is done in a um spine position but then in
The O you flip the patient in a prone position and that will change the configuration of the spine so it was a huge challenge to get this uh reference which are the green and red dots because if this surface you digitize is not the same like in your preoperative planning
The computer will tell you well there’s something wrong um then um what we started with first in spine cases so thoracic spine was always very good but then during surgery you got this feed back okay matching error to high is what I just mentioned surface matching doesn’t work that was the end
Of the procedure because if you don’t solve this problem and this was the time where my B said okay sorry I’m doing it now in the standard manner um where we had to stop that but sometimes it worked quite nicely so we did this at that time
Of type of spine surgery but used this uh computer systems to uh get a perfect position of um the pedicle screws we have to upload all this data set so it’s preoperative data set of the CD scan and the CD scanner got better and better meaning more slices more slices more
Slices so it was a challenge for the system can you upload all the slices uh no you can’t so there was always a limit you had to talk to radiologist please don’t do so not so much sis I’m happy with a very standard basic CT scan my
Computer can’t uh can’t eat that and but what we then did was perfect so we had a perfect position of the P the accuracy of the system was always good uh or to say p perfect and this was the major argument in continuing um with this with
That system so in 2000 we started to transfer this pelvic application into uh this spine application into the pelvis starting with s I screw placements and from the beginning it work quite nicely except the matching again there’s an huge issue in the spine you have a very nice anatomical different surface each
Vertebra is a little bit slightly different and then you can discriminate where you are if you go to the Elia Crest and take a few points that could be in the beginning in the middle or somewhere else so matching was a huge Challenge and you always have to have
Both helc um wings and you can see here we inserted even little screws before surgery before we did the CT scan just to have a fixed point where we can do the matching not really the way you would like to do that um um but then if
You have succeeded that the next step is always the then you get this warning then you have to got there’s something to be sorted in the wires I’m not an engineer I could not do that so it was always the end of the surgery yeah but
Promising uh is we will start in 10 seconds okay then I start communication with the camera and FAL error in the camera system okay so this is um how we learned to do computer assisted surgery at the beginning um and you I can tell you you must be very patient in these
Things that’s exactly the time point where the AO started to um introduce a expert group just focusing on this new technology because Theo said okay we would like to see whether this is worthwhile to follow up is this the future of trauma surgery or not and from
The beginning you can see him here they David Kayla and the young Gard um we were Partners in this expert group and we spent many many years just in following up this technology um from a clinical uh standpoint and that we were always in opposition to the engineers so we made
The clinical demands and David was one of them who really said I want to have this one and the engineers said oh my God you really want that in the lab it works so nicely but we told them no it does not work nicely in the O and you
Can see where in different locations in the globe that’s typical for the AO we even got to Australia because we thought we have to tell them there’s new technology available on under um and so this group and here you can see the group gets older and older more gray um
And unfortunately say in December we had the last meeting of the group it’s now finished because of um new ideas so coming back to navigation then we go into trauma so we said okay putting screws in in FAL neck makes sense then we started to do that but you can see
What you need and Technical equipment the lower left to do only these three screws if they are in they look beautiful um but the the effort to do that is so much that you do it once or twice for a paper but then you don’t do it anymore
Um so then uh when we were more confident system we went up to the turus spine you can see that’s the clear benefit if you the small pedicles with small cruise to to fix to do a fixation that you’re really lucky if you do navigation but again you can see see
That the lower right all these cable this uh this reflectors was not a good thing to do that and then the new generation of the CR AR uh came up um which were um adapted to our needs and this was a huge step forward and um but
The issue was always the beginning if you do these cans it’s a huge of radiation um so at the beginning we we did a study very early where we use this TLD this is a little uh crysals that just capture all the radiation and you
Can put it on the patient we put it on the CR and under the patient above the patient and if you heit them they will tell you what you did on radiation on this patient and the result was convincing that if you do this was a spine procedure the left side you can
See that’s the average dose you uh you’re using to do a spinal procedure um using a CR AR if you do it CT based that’s the next one it’s the lowest one because you rely on a preeptive data set but as I told you CT interoperative turnaround the patient is a challenge
But the C navigation uh and the iso the 3D navigation with on the right side clearly reduced um the intive radiation exposure to a minimum and this was one of the strong arguments to continue with this uh um technology because we as the surgeons are the one
Who get the radiation every date the patient doesn’t matter he gets it once hopefully once in his lifetime uh so he will take that but for us in the whole or Personnel I think it this was one of the convincing arguments and as time goes by these um platforms getting
Better and better this is the SEO it’s code you have one here um this was the first system where we uh said okay we want to have de in trauma when we asked Simons to get this for trauma they said well what’s trauma we are not we don’t
Know what is trauma they are strong in cardiac surgery neurosurgery but we told them it will work and so this is where all this started and this you can see what’s the advantage if you have a new hospital building because to get this technology in an o That’s challenging
Yeah it’s spacewise and all these um wirings because everything is connected is a challenge and you have a control room and you have a a generator room to produce the energy and all these things but building a new hospital um it’s easy to integrate that and what I did because
I’m still and was fascinated from this technology these three o are link so we have one navigation system for three of them so there one computer system that just distribut the signal to the or and so we have three um or suits in a row where we can do computer assisted
Surgery now we have the highend one and two with a lower um um performance and so it looks like at the beginning and then you get all the stuff into it and what the system is is that this robotic CR in the OR table they are linked so
That means the CM knows at any time of the day where where the O table is and vice versa because this is a closed system you can identify any structure that you xray in a three in an XY Z axis yeah and by that one you can register
The patient while scanning the patient and then just transfer the data into navigation system and so this is just a few data so in 10 years we had 3,860 patients in this room treated so it’s really used during um the week day every day and you can see who is the
Lead trauma so we are the ones who use it most but we share this or with vascular surgery and cardiac surgery and sometimes neurosurgery um use it as well and then it makes sense to make an investment for a system like that one in trauma you have done more than 2,000 U procedures
And you can see spine is leading of course because um this is what we do much more often but in the second place is now pelvic surgery yeah um then we do some tumor and some so we always looking at what can we do and so miscellaneous is just K uh but whatever
We thought we can do we could do so um and this is just uh last year um so it hasn’t changed much so it’s still spine is in the lead followed by pelvis and some oncology stuffff um and then we used the pandemic because then we shut down part of the hospital
But trauma was always uh uh online but I said okay we will we can survive this uh three months not having the feno the SEO and then we got the new system which is now called feno seens tell you it’s phenomenal so it’s a nice system um but it’s it’s stronger performance it’s
Quicker and it’s a better Imaging and the beauty for me is always I can control the system I don’t need anyone else so you see the touch pad on the right side that’s sterile covering and whoever does surgery controls that so you don’t need any other person to do
That and you can see the new system is rather quick so this is a scan of a pelvic the size of the images that you have a whole Paris both size both are taba both proximal femur uh and it’s a huge image quality we spend a lot of
Time in draping set scenarios so we do a lot of dry testing now we are very to a um to a level that it works quite nicely uh because if you don’t do all these uh um consider all these things you run into drers when this swings around the
Patient very quickly you can’t stop that there’s a a emergency stop in it if it touches the or table then it will stop uh but anything else it will just moved away including your reference which is very important for doing surgery and then we have a lot of
Displays just all around the walls that everybody who’s involved in in the case can see has a direct line to a monitor and then everything is ceiling mounted or we do not have any of these cables on the floor anymore um and so this is um very good standard setting a few
Examples oncology so this was one of our first cases this was a very rare G1 AA of the oium posterior part and um so the challenge was to get this as an our zero resection um and then without destroying the whole pelvis and then we did a pu
Planning that okay we get two screws into the posterior pelvic ring to stabilize the patient and then we would use the same data set to do a guided to section and what you can see here that we did the screw inserted the screw and then we had guided chisels and we just
CED out the tumor uh by image guidance and so the the limit was 1 cm to to the tumor to get an R zero reection U it takes some time but it’s very nice because you have always a full control where you are at the moment and where is
Your T tumor um so we could do that that’s the final result you see we removed all the posterior part it was R zero P juice was very happy but the P pelvic was still stable uh using this two screws and so this we now follow up
This patient now in more than 10 years he doesn’t have any recovery uh um of this tumor has a full recovery of the tumor then if you have a combination of bone and soft tissue you can use your preeptive MRI data and fuse it with preeptive CT scan um this is a
Metastasis in the spine area green is the tumor and then we prep diffuse these images and then we go to the are and that what we then can do we do a image guided positioning of the pedicle screws and then again we use guided instruments
To resect the tumor uh to achieve an R zero situation after that and this is also very helpful because as you know the the borders of a tumor are not really clearly seen if you do surgery um but if you get this information out of the preeptive MRI
Then you can get enough distance to the tumor while doing the surgery um same for Coda Pro uh tumor in the pelvic preoperative fusing of both images inop if you have a slider you can switch between the full MRI and full CT VI so whenever what you are interested in just
The bone for the screws or the tumor for a section you just slide in that um and it’s a very straightforward process pelvic so these are just examples where you would like to say well that’s a beautiful screw if I can do that very quickly that helps the patient but
Sometimes it’s very narrow and so that’s exactly the point where you can do um computer guided surgery that’s a case where I do not need computer guided surgery but I would do it at at the uh at the phenos suite because if you do in this type um standard surgery using this
Pelvic plate then you can use the same system for the introperative implant positioning control and reduction control because you can see that’s the mprs what you can do in in operatively that’s a clear view of the whole atum and so intraoperatively you’re just clear say okay that’s a good reduction
The implant position is perfect and we do not do any CT scans after surgery because if something goes wrong in here we have a let’s say one of the screws is not that perfect then we would change it immediately doing a second scan and so by that one we can we reduced the
Revision rate of cases to zero uh which if you do that uh poopity scanning if it’s a minimally displaced fracture like this one then you can do a lot of screws planning and you can see the visibility or the the the representation of the bone is perfect um and then you do all
These scre plannings at the end of surgery you do an NPR which is not super sophisticated your Radiology does it but you can learn it in 10 minutes um then you have this final control and you say okay screw position is good reduction is good the case is done no further control
Need it yeah um then by time you get more um confident in the system this was a 12 year old boy was overrun by a a truck he had this communed cycle fracture and we said okay well 12 years um open surgery may be not the best
Thing and then what we decided that we plan just a long screw Crossing both sides of the uh poia wing and the sacrum to stabilize this fracture uh um this is the screw intraoperatively which we reconstructed then and so we had only two step incisions and you can see that
This at that time this was the longest screw available on the market was able to stabilize the posterior pelvic ring and there was an uneventful recovery of that one meanwhile we get longer screws um C is producing longer ones then spine surgery just highlight this is a
90-year-old female in a nursing home and you can see that um th23 fracture there and because of the deformity of the spine it’s the vertical fracture line and this is a highly instable instable situation but as you can see in this scout VI it’s a huge osteoporotic spine
And if you do this in a standard open procedure you may get into troubles so we used our computer system and you can see now the image quality is not good because it’s a severe osteoporotic bone but it’s still good enough to decide whether your pedical screws are in the correct place and
Interestingly on the right side you can see that’s the AP posttop x-ray okay that’s a horizontal spine and so both the fource screws are just above each others but it’s a proof of the accuracy of the system because they’re exactly at the correct uh place and this is done by
A step inis so it does not harm to the patient after a few days she went back to the nursing home yeah you can see that’s the AP and lateral so that’s the lateral postoperative with that image doing surgery intraoperatively I think you’re are really lost and I think
That’s the beauty of the computer system that this Bridges the um the the part between image quality and the need of the patient okay what are we doing today in a two weeks time hopefully we will introduce the robotic arm um it’s uh in the delivery process why should you add
An robotic arm So currently if you look at your cases the challenge especially in the pelvic area is if you have an oblique surface and you try to get a kwire or drill you very often slip along the surface and you can’t hold the drill sleeve the guided drill seve as tight as
You wish to do that uh not to slip off but this robotic arm does exactly holds tight and doesn’t do anything else and this robotic c um we will use it for pelvic surgery is just a guided uh drill sleeve uh holder but you can roughly
Adjust the robot and then the robot will automatically go into perfect trajectory of the screw you’re going to introduce this one and then he it will hold still as long as you want you can do whatever you want it’s very strong you have if you move that the whole or table will
Move so it’s a um strong fixation and then you can do your procedure just using this uh the trajectory given by the robot I think that’s it’s it’s not a huge step but it closes the gap of 10% of the cases where where you get into Troubles by getting the accuracy when
Slipping off and so and it’s totally integrated to the system and I think that this part of robots for our profession foric trauma makes totally sense um because it eliminates uh weaknesses in holding some aiming devices I told you at the beginning so when we studed these things we did this
Type of um uh radiation thing so it’s clearly it’s less radiation when we do the scan everybody goes out of the O room also even anesthesist leave the or room so we do not get any radiation when we use the system but if you’re inside inside the O
Room then you have to be aware that that’s the heat map of the system okay and you can see that that’s not the standard cm it’s an angiography system which produces a lot more radiation and you can see that it’s not really advisable or wise to stay close to the
Patient when you’re are scanning the patient um needless to say the darker the color the more radiation you get and so um radiation is an issue but it’s not if the setting is okay and nothing is perfect you can see here sometimes you need some additional fixation devices
Like that one otherwise it does not work um so you can get all your fantasy in this development there a bride open field for new ideas or even research but uh it’s a lot of fun and helps U the patient thank you very much anything about
This on your robotic arm if you if you’re holding to navigate a drill guide the 10% of the time there’s is that because the drill will the guide will show a straight trajectory but the drill will bend or slip but the guide still looks like it’s shooting straight
Down your trajectory so that the drill will wander yeah and you get a it’s a combination of left and right hand so usually you have the left hand have the drill sleeve right hand goes in with the uh with the uh drill then you push down
The T sleeve like at the surface of the pelvic and then you feel it doesn’t not fit there then you try to press it when you press it you slightly angulate it automatically to get a better fixation and then if you insert the drill uh then
You bend back and then you have a combination of a slight tilt in your in your um in your drill sleeve and a double tilt because you press the the drill in the opposite direction and at the end this always means that you have a deviation of the entry point and a
Deviation of your exis usually it’s okay it’s not super uh um super dangerous for the patient because you always have a wide safe Zone but sometimes it’s really annoying if you don’t succeed exact the one you planned yeah does the computer Mar that when you take your scan
And where you said you put your screw and then where it actually ends up or is it something you just see I intended it to be here but it’s actually slightly off not automatically what you can do that you do upload final scan again in the navigation system then you can
Fuse the planning data set data set and then you can see the difference but don’t and it’s the end of surgery okay that’s it thank you very much for thank very much