Robotic Knee Replacement A Transformational Journey

After 25+ years of experience & performing more than 19000 knee replacement surgeries I was inspired to give even more better outcome to my patients reading the adage by Peter Drucker “Knowledge has to be improved, challenged and increased constantly, or it vanishes”. I started delving in recent advances in Arthroplasty & concluded to unlearn my masterly learning of conventional knee replacement to learn intricacies of Robotics in Arthroplasty following the age old saying by Eric J Zelenski ”Be a learner first, a master second & a student always.”

Arthroplasty has come a long way since it was first performed in the early 60’s. Earlier knee replacement was offered as a last resort to the patients with severe arthritis who were not benefited with other treatment options. Over the period with all technical advances, better training to surgeons and increased awareness amongst population it has become one of the most asked for surgical procedures with better, safer & successful results.

Addition of Robots in knee replacement surgeries in recent times has helped the surgeons to do the surgery with much more precision. In Robotic knee replacements the surgeon takes help of computer assisted software & navigation to select size / axis / placement of implants for better implant stability leading to reduced risk of implant failure. In addition, it helps to accomplish the surgery with lesser soft-tissue dissection & bone removal resulting in a shorter surgical time which helps in reducing risk of infection & post-operative pain.

Flow of the Robotic Knee Replacement Surgery

Step 1: Patient Selection

After clinical & radiological exami-nation, the selected patient is be advised for specific CT scan imaging of knee joint.

Step 2: Patient’s CT Scan

CT scan imaging is mandatory before the surgery as bones & joints of every individual are very specific & more-so with our Indian patients whose bones are smaller than westerners. Thus, the total surgery is planned for customised joint size & its alignment.

Step 3: 3D Model Planning

CT scan images are uploaded to robotic J planner. After their conversion to 3D bone model total surgery is planned virtually.

Step 4: Verification of Planning

To conduct the surgery, first the Patient is connected to the robotic unit and thoroughly stabilized for the surgery, as very minimal jerk like coughing by patient even, can pause the robot to perform for perfect precision. Next, the registration process on the patient’s actual bone with the help of Robotic probe is done to integrate the 3D bone model constructed using the CT images to match with patient’s native bone.

Step 5: Surgery Conclusion

After in-depth verification of the data, the robotic arm is given the command to perform the surgery as per the plan in accordance with the size, position, alignment, angle and direction of the artificial implants as was decided during the virtual surgery in J-Planner process. After all required bone cuts done by robotic arm the robotic part of surgery concludes. After this, the remaining part of the surgery is executed using pre-selected implants as done in conventional joint replacement surgery.

Advantages of Robotic Knee Replacement:

Increased accuracy: In the present era, greater precision is achieved by robotically assisted surgeries, which speeds up the recovery and produces better outcome. Using traditional surgical expertise with the additional help of a fully automatic robot, the whole process of Knee Replacement Surgery becomes more precise & flawless leading to enhanced satisfaction& reproducibility.

Reduced risk: A robotic-assisted knee replacement helps delivering a better aligned and balanced knee using sophisticated computer software to make 3D bone models utilising patient’s CT Scan images of his bones & joints. On these customised 3D bone model & performing a virtual surgery to assess the implant size/alignment/placement prior to the actual surgery on the patient, the surgical satisfaction is exponentially increased.

More precision: After the integration of patient’s own native bone details provided during actual surgery and the technical details ascertained during virtual surgery in computer system, ‘CUVIS’ the one & only fully automatic Robotic System for joint replacement proceeds for highly précised bone cuts. The bone cuts by Robotic Arm are accomplished by miller cutting tool working in six different axes which gives up to 0.5mm precision with a controlled speed depending upon patient’s bone quality. This helps in more accurate implant fixation resulting in more natural feeling post-surgery.

Quicker recovery: Robot in knee replacement surgery helps in cutting less bones and reducing soft tissue dissection around joint resulting in faster & better recovery. This facilitates the patient for earlier discharge & reducing hospital expenses and chances of infection. All these are key factors for more satisfying outcome after surgery.

Surgeon-driven: Contrary to the myth that the Robotic Knee Replacement Surgery is completely automated by the robot, this surgery is essentially surgeon driven. The Robotic Arm only cuts the bones as per technical inputs received during planning stage rest whole surgery is done by the surgeon depending on his expertise.

OR Specification: To accommodate the Robotic Arm System the operation theatre should be of optimal dimensions, so that the man & machine can work in coherent efficiency. At Sterling Hospital Ahmedabad, we have the privilege to have a dedicated OR especially for Arthroplasty only, which itself is great boon for Robotic Knee Surgery.

My Take – After 1 year with 125 & Counting Robotic Knee Replacement Surgeries:

The more accurate & précised help by ROBOTIC SYSTEM in the surgery gives more improved quality of life & better satisfaction to the patient enhancing my sense of accomplishment in view of the following observations:

• Bone cuts taken by Robotic Miller helps in better & accurate implant placement resulting in more natural feeling after surgery. This will probably reduce rate of revision surgeries in view of longer implant survivorship.

• Use of fewer instruments, especially not using the Intra-Medullary Rod, reduces chances of complications like Pulmonary Embolism; Fracture; Rate of infection.

• Less soft tissue handling reduces risk of injury to adjacent tissues resulting in more safety, also help reducing postop pain & lesser blood loss.

• Initially it took fairly long time in finishing the surgery but gradually it is decreasing nevertheless, it is only 15-17 minutes longer than the conventional surgery now. I have a high confidence that down the line with the help of my team I will be able to finish it in a shorter time than taken in conventional one.

• Better in severe deformity as preop virtual planning gives great insight for corrections.

• Earlier & faster rehabilitation reduces the hospital stay.

• Few patients who underwent robotic surgery on the 2nd knee were more satisfied in comparison to the earlier conventionally operated side.

All these have made overall outcome of the Joint Replacement Surgeries more satisfactory for the patients & with continuous evolution to avail benefits from potential newer advances, the robot is acting as an efficient tool for me to enhance the precision in my surgeries making my endeavour more fulfilling and corroborating the saying by Gail Devers “Every Accomplishment starts with the Decision to Try.”