Synergies

Professor Josten, what do you think sets the Univer­sity Hospital in Leipzig apart?

Leipzig University Hospital is the second oldest univer­sity hospi­tal in the German-speak­ing world. It has a very good repu­ta­tion, which is also reflected in recur­ring awards. Eight years ago, I was faced with the chal­lenge of merging the speci­alities of ortho­pedics and trauma sur­gery. I suc­ceeded in building the Clinic for Ortho­pedics, Trauma Surgery and Plastic Sur­gery into one of the major univer­sity inst­itutions in Germany, both in terms of patient numbers and the medical spec­trum. The univer­sity hospital is certi­fied as a Level 1 trauma cen­ter and has the high­est level of cer­ti­fi­ca­tion as an endo­pros­thetics center as well as in spinal surgery. In addition, the clinic has very modern struc­tures. The posi­tion of clinic director is not for life, as is common at most other univer­sities in Germany. The execu­tive direc­tor is elected by the five equally appointed profes­sors of the Trauma Surgery, Ortho­pedics, Spine Surgery, Arthros­copy Sports Medicine, and Plastic Sur­gery depart­ments on a regu­lar basis, which strength­ens the team spirit. I am proud that we have done so well in Leipzig so far.

Before you became med­ical director of Leipzig Univer­sity Hospital, you worked in trauma sur­gery for 40 years. What is so appeal­ing to you about this specialty?

Patients are often in life-threat­en­ing situa­tions. You have to be able to make deci­sions quickly, and have good, broad-based med­ical knowl­edge and man­ual dex­ter­ity. I have never regret­ted my deci­sion to become a trauma sur­geon because of this fasci­nat­ing combination.

What role does imaging play in trauma surgery?

Optimum imag­ing is indis­pens­able in trauma sur­gery and an essen­tial com­po­nent of quality. Good, sharp images are impor­tant for making a diag­no­sis. But good imag­ing is also essen­tial during the proce­dure to objec­tively assess sur­gical steps. After, or better, during the oper­­ation, good images can be used to check if the surgeon is satis­fied with the result or whether he needs to make further adjustments.

Why did you decide to use a mobile C-arm for imaging?

I’ll try to explain it like this: If I can get a car with four-wheel drive, I’ll take it. Since the 1980s, when the first mobile C-arm from Ziehm Imaging came on the market, it has been part of my daily sur­gi­cal routine. Before that, when there was a frac­ture, usually an X-ray assis­tant had to come from the X-ray depart­ment. Many of those involved in the opera­tion left the room, while some, pro­tected by lead vests remained with the patient. X-rays were taken and stored on a cas vests sette. Worst case, this then had to be taken to the radi­ol­ogy depart­ment. It could take up to 15 min­utes to get an image, which was some­times under­exposed or blurry. Intra­operative imaging has greatly improved this process. The mobile C-arm is brought into the OR, the images can be taken right away and dis­played on the monitor.

For a long time, 2D images were com­mon in intra­operative imaging. Especially in ortho­pedics and trauma surgery, 3D imaging has been gaining in impor­tance for years. What advan­tages does a three-dimen­sional image offer?

We were one of the first pilot clinics to work with 3D tech­nol­ogy in imag­ing when it entered the market. It was like watching a movie with 3D glasses today. Thanks to the three-dimen­sion­ality, you dive into the ana­tom­ical struc­ture in much more detail. With two-dimen­sional X-rays, you only see two planes. In between, how­ever, there are umpteen degrees of angles that obscure some­thing or that can­not be visu­al­ized prop­erly. To get a usable image, you would often have to take count­less X-rays. With the 3D scan, there is much less X-ray exposure and ana­tom­i­cal struc­tures are much easier to see. This has helped me enor­mously, espe­cially with com­plex frac­tures, to bet­ter under­stand the frac­ture and repo­si­tion­ing mech­a­nism on the one hand and, of course, on the other, also to check the result after the oper­a­tion. The 3D image is much more infor­ma­tive and mean­ing­ful because you can see all the levels of the joint and addi­tional levels that are easier to miss in a 2D image. In my opinion, the advance­ment in 3D imaging has brought a huge increase in knowl­edge and a signif­i­cant improve­ment in the quality of care.

You mentioned intra­operative control with the help of a 3D scan. How has this helped you with your work as a trauma surgeon?

I was one of the first trauma surgeons to argue that intra­operative 3D control should become a must. It gives you the oppor­tu­nity to assess the out­come before the end of an oper­a­tion and thus pre­vent follow-up sur­gical pro­ce­dures, including anes­the­sia. After all, how do you explain to a patient at the X-ray check the next day that the sur­gical result is not opti­mum? That he must either accept the result with all its con­se­quences or agree to another oper­a­tion? Another argu­ment in favor of intra­opera­tive 3D scan­ning is the very good image quality. In the past, espe­cially with com­plex frac­tures, reposi­tioning maneu­vers, and osteo­syntheses, a post­operative CT scan was often neces­sary to check the result of the pro­ce­dure. Today, 3D imaging is often so good that there is no longer any discern­ible dif­fer­ence in quality. In addi­tion, the signif­i­cantly lower radia­tion expo­sure bene­fits both the patient and the user. In my opinion, intra­operative 3D imaging is now an indis­pens­able part of any advanced trauma sur­gery or orthopedics OR.

How do you think 3D imaging will change in the future?

If the focus of imaging sys­tems is on the quality of imaging, reduc­tion of radi­a­tion expo­sure, as well as ease of han­dling, and this is expanded to include dig­i­tally net­worked sys­tems, there is enor­mous poten­tial for devel­op­ment. In the future, it may also be pos­si­ble to bet­ter image soft tis­sues and ves­sels. I still see poten­tial in these areas to enable the prog­ress of medi­cal spe­cial­ties beyond trauma surgery.

It is also pos­sible to per­form navi­gated pro­ce­dures with C-arms from Ziehm Imaging. How impor­tant was nav­i­ga­tion to you during operations?

I was a fan of nav­i­ga­tion from very early on. I started doing CT-based nav­i­ga­tion about 20 years ago. At that time, it was still very cumber­some, raised a lot of ques­tions, was time­con­sum­ing and not of suf­fi­cient quality. I decided at that time to wait for fur­ther prog­ress in the tech­nology. When image inten­sifier-based nav­i­ga­tion came on the mar­ket in the mid-2000s, I started again, and I quickly real­ized that the develop­ment was a quan­tum leap. The advan­tages of 3D imaging that we just dis­cussed could then be com­bined with nav­i­ga­tion. The accu­racy was excel­lent. From then on, it was pos­si­ble to per­form far more mini­mally inva­sive sur­geries and reduce sur­gical dimen­sions. On top of that, the image size expanded thanks to the intro­duc­tion of the flat panel. With the larger images, it was pos­si­ble to navi­gate well and safely in more com­plex, larger body regions. Since then, it has been a must for me to per­form cer­tain pro­ce­dures with nav­i­ga­tion. One needs sig­nif­i­cantly fewer post­opera­tive control CTs, since the 3D images obtained intra­opera­tively with the mobile C-arm from Ziehm Imaging offer good image quality. Never­the­less, in my opinion, it is impor­tant to be able to master the sur­gical chal­lenges with­out nav­i­ga­tion and to be tech­nically versed in the sur­gical rep­er­toire so that it’s pos­sible to operate with­out nav­i­ga­tion at any time if nec­es­sary.

How do you see the market for nav­i­ga­tion and robot­ics?

We, as a hospi­tal, are sure that the advances in imaging, nav­i­ga­tion, and com­puter-assisted sur­gery are unstop­pable, as they lead to a huge improve­ment in the quality of many inva­sive pro­ce­dures. That’s why we estab­lished the ‘Center for Com­puter Assisted and Navi­gated Sur­gery’ last year. We are also getting three state-of-the-art oper­ating rooms this year, which will be equipped with the latest CT and 3D-assisted navi­ga­tion sys­tems. The qual­ity stan­dards of sur­geries are so high that with­out such sys­tems it is no longer pos­si­ble to meet the demands of today’s high-tech medicine.

Do you think navi­ga­tion will con­tinue to gain in impor­tance in the future?

You can com­pare devel­op­ments in this area with road traffic. In the past, many people claimed that they didn’t need a navi­ga­tion sys­tem in their car because they had a strong sense of direc­tion. Today, almost no one drives with­out one. People know that they might not need it every day, but if the route is unknown or they are looking for the fastest route, they inevitably fall back on navi­ga­tion. It’s the same with navi­ga­tion in the oper­ating room. That is why I believe that there is still poten­tial in many areas where it is not yet con­sid­ered today. Since navi­ga­tion sys­tems deliver an improve­ment in quality, they will become even more important.

Let’s take another look at the past. When and why did you decide to work with Ziehm Imaging fluo­ro­scopy systems?

It was so long ago that I can’t really say – cer­tainly more than 30 years ago. I noticed Ziehm Imaging mainly because the equip­ment was much handier than others on the market. Since space in the oper­ating room is usually very lim­ited, this crite­rion was and remains impor­tant. In addi­tion, Ziehm Imaging offers user-friendly fluo­ro­scopy sys­tems. But of course, the very good image quality is the main thing. I’m also con­vinced by the good oper­ability, the easy maneu­verability, and space-saving.

You have worked a lot with Ziehm Imaging in recent years. What can you tell us about your col­lab­o­ration?

When an inno­va­tive com­pany like Ziehm Imaging meets phy­si­cians who are inter­ested in new devel­op­ments, a con­struc­tive col­lab­o­ration almost inev­i­ta­bly results. In my expe­ri­ence, Ziehm Imaging is very open to feed­back from phy­si­cians about their sys­tems and the resulting needs and wishes. At an early stage, we decided on devel­op­ment proj­ects with Ziehm Imaging and con­ducted clin­i­cal and ana­tom­ical studies to find out, for example, how to improve image quality and reduce radi­a­tion expo­sure at the same time. A trusting and result-oriented col­lab­o­ration like this gives rise to new proj­ects, such as sys­tems that will ulti­mately be launched on the mar­ket for the bene­fit of the patients.

What added value do you see in work­ing with Ziehm Imaging? 

For me, the most impor­tant aspects in my direct col­lab­o­ration with Ziehm Imaging were the tech­nical pro­gress as well as the practice-oriented appli­ca­bility and, ulti­mately, the bene­fit for the patient. On the other hand, the inter­national con­tacts that were estab­lished through the col­lab­o­ration and that then developed into global partner­ships were also impor­tant. Guest physi­cians came from a wide vari­ety of coun­tries and were able to see the tech­nical pos­si­bilities of the systems for them­selves. We were able to train doctors here in Leipzig, which also led to an exten­sive medi­cal exchange. This was very impor­tant, espe­cially for me as a scien­tific univer­sity lec­turer. These are all very posi­tive aspects of the col­lab­o­ration between medi­cine and industry. Not only are pro­ducts devel­oped that bene­fit the patient, but these pro­ducts are also accepted inter­na­tionally and scien­tif­ically. This con­trib­utes to the repu­ta­tion of Germany as a cen­ter of manu­fac­turing and science.

You are now the Medical Director of Leipzig Univer­sity Hospital. How has your col­lab­o­ration with Ziehm Imaging changed in this role?

Due to my cur­rent posi­tion, I no longer work person­ally with Ziehm Imaging. How­ever, Leipzig Univer­sity Hospital is still a partner. Of course, I monitor devel­op­ments, keep in touch with medi­cal col­leagues and users, and make sure that they have the best pos­sible equip­ment for the best pos­sible therapy for our patients. And I hope that Ziehm Imaging will con­tinue to dedi­cate itself to research and new develop­ments in exchange with medi­cal pro­fes­sionals, even with­out my spe­cific involve­ment.

What opportunities do you see in the future for Ziehm Imaging’s col­lab­o­ration with Leipzig Univer­sity Hospital?

On the one hand, the busi­ness relation­ship con­tin­ues, as we have Ziehm Imaging equip­ment in our hospi­tal. That means the coop­er­a­tion will continue. But of course, I would also like to see scientific col­lab­o­rations in the future with the col­leagues who now run the Clinic for Ortho­pedics, Trauma Sur­gery and Plas­tic Sur­gery. I would also like to see com­pa­nies getting involved in our new center for robot-assisted and navi­gated sur­gery. After all, estab­lishing a leading inter­national center for tech­ni­cally-assisted sur­gery can only suc­ceed through good coop­er­a­tion. Both sides must approach each other, i.e., the industry, the physi­cians, and the clinics must approach the manu­fac­turers so that joint projects can be realized. That’s why I’m sure that there will be fruit­ful coop­er­a­tion in the future as well.

And finally, a look into the future: How do you envision the opti­mum clini­cal work­flow in ten years? 

My vision of a future surgi­cal work­flow could per­haps best be com­pared to auton­o­mous driv­ing. You sit in a car that drives itself based on naviga­tion. It warns you when there is a risk of traffic jams, brakes automatically, and never drives too fast, so that the driver only has to intervene if he doesn’t trust the automatic system or gets into an exceptional situation. Similarly, I can also imagine future interventions consisting of a combination of robot­ics and navigation. Certain surgical steps would take place fully auto­mat­ically and sur­geons would only have to inter­vene at critical points, and per­haps not even neces­sarily be on site in the operating room.