Cutting Edge: How HoloLens2, a new imaging device, guided an innovative shoulder replacement

CHEAPER TECH TOOL THAT HELPS IN PRECISE SURGERY

“So far we have always experienced cutting edge technology introduced at a premium cost. A surgical robot costs anything between Rs 6 to 10 crore. The HoloLens 2 comes at a fraction of that cost and for an economically-conscious country like India, where health costs are unaffordable, HoloLens 2 is going to be a game changer,” Dr Babhulkar says.

When he is operating with the HoloLens2, he has several screens in front of him and the most vital is the 3D imagery of the patient’s CT scan. “I can rotate, enlarge and superimpose this image over the exact bone that I am expected to replace. I use gesture controls in the air to manipulate the 3D hologram without compromising the sterility of the field. That way I have this pictorial information at my finger tips and keep to the sterile requirements of surgery. Second, I upload the patients’ X-rays and clinical information in a separate space. Third, I have a 3D graphic step-by-step guide of the surgical procedure at hand, in case a young surgeon needs it. Far more significant than these is the ability of a remote surgeon or student to have a seamless, unobstructed view of my entire technique, sitting in any city of the world. That to me is unlimited access to the highest level of mentoring, unparalleled in any branch of education. Imagine how a young surgeon in Kenya with a Hololens2 can be trained, tutored and assessed without compromise by a surgeon in India without leaving his premises. All both would need is a good seamless internet connection,” Dr Babhulkar adds.

HOW SUCCESSFUL HAS THE DEVICE BEEN?

So far, the surgeon has performed nearly 12 mixed reality assisted replacements that involve uploading the patient’s CT scan to the Hololens2 with special protocols.

Dr Babhulkar began training in the HoloLens 2 in July 2020 and after mastering the skill curve, started integrating patient data. Conventional CT scan files must be converted with a special software and uploaded to the HoloLens 2 chip. It takes about two hours to prepare a case and integrate it into the HoloLens2. After a trial run, two patients were operated in November and December with HoloLens assisted Reverse Shoulder replacement.

The first patient was a 72-year-old woman with a massive tear of her rotator cuff tendons that led to secondary arthritis of her shoulder joint. The woman came with a very stiff shoulder joint. She was unable to comb her hair or touch her back. Besides, she also had severe pain in her shoulder which became excruciating at night. She was from a different city and was delayed due to the lockdown restrictions. Her CT scan images were converted with a special protocol to create HoloLens 2 compatible 3D images.

The team of surgeons had to establish a secure broadband, providing a 90 MBPS seamless transfer of data. The plan also included a watch-in by two eminent shoulder surgeons from Paris, France and London, UK almost 7,300 km away. away. Among them were Thomas Gregory from Paris, the brain behind the concept of integrating HoloLens2 and Shoulder Replacement protocol and Prof Roger Emery, London. They were receiving the exact surgical field that Dr Babhulkar was looking through the HoloLens2 Visor. “They had the perfect, unblemished, live picture and could follow my every gaze and movement. Several times during surgery, they stopped me and asked me to explain my atypical technique of performing a particular step during surgery. The surgery – A Reverse Shoulder replacement – went through smoothly. The patient recovered and has now started her exercises. She is almost pain-free and unshackled of her stiffness and disability,” Dr Babhulkar says.

WHAT IS SHOULDER ARTHRITIS?

Shoulder arthritis is still unrecognised due to a lack of focus and the availability of a few shoulder specialists. It, however, remains the third most common cause of arthritis and can be very disabling. “A perfect surgery, pain relief and function restoration is a big challenge. After the initial success with knee and hip replacement, other joints such as shoulder and elbow were replicated with almost similar success. It was appropriate to push the envelope further and this century, technology was married to surgical skills, to introduce the engineers to enhance surgical skills and precision,” Dr Babhulkar says.

HOW DO THE SCANS WORK?

Dr Gregory collaborated with Microsoft and helped develop algorithms that would be led by the operating surgeon’s eye movements and integrate real 3D imaging. The concept was to improve accuracy to the last millimetre. Alex Kipman, a Microsoft scientist, elevated the original Kinect line of motion sensing device to an elite, powerful and technically superior HoloLens 2. The visor can integrate a virtual image in 3D and also allow gesture control and simulation. “This level of mixed reality has never yet been integrated into surgical planning and execution. I have always used 3D CT scan data to plan my shoulder replacements. These advanced 128 slice 3D CT scans (Till now the most advanced CT scans at Deenanath Mangeshkar hospital, Pune) are then printed on plain paper with multiple images. With Hololens2, I have the entire set of patients’ CT scans and X-ray within my eyesight,” Dr Babhulkar says.