Robotic surgery in total-knee replacements for Osteoarthritis

Dr Irengbam Mohendra Singh
Osteoarthritis (pain, swelling, stiffness and grating sensation) of knee joints is not that common in Manipur, but they do occur. Total-knee replacements for severe osteoarthritis (OA) of knees has almost 100% success rate. The cost in India is around 2,00000 to 3.50000 rupees for a single knee replacement. OA affects mainly the weight-bearing joints: hips and knees, and the finger joints, mainly the tip joints with nails.
The use of robotics in surgery has been gaining momentum in the West since it began in 1985. It has been tried in various surgical conditions. Assisted robotic surgery for total-knee replacement is fairly new.
Treatment of OA of knees depends on the severity when you move the knee. It ranges from simple pain killers and stronger pain relievers like Ibuprofen to steroid injections into knee joints, and finally total-knee replacement surgery. OA mainly affect the elderly, especially women. Many long-term sufferers are quite likely to have depression. In the UK, there are civil society groups that give moral support to the sufferers, asking to take ownership of their own condition ie to have a positive attitude to stay alive.
Such a stance in any life-exhausting situation would be a bonus. Aussie icon Kylie Minogue (50) comes handy. She has had her heart broken multiple times. She had breast cancer and chemotherapy (2005), and had a nervous breakdown when her French fiancée (30), broke off their engagement (2017). Undaunted, she has now a new beau, a British guy, and has released her latest album, “Infinity goes for ever” with confessional lyric. She sang it as a response to ageism with encroaching morbidity and mortality. “Live your life like you’re/ every little moment stealing in time/ Infinity goes for ever/Lay your life on the line.” She shows life is a roller-coaster ride with ups and downs.
Tackling the nostalgia bug in osteoarthritis. A year ago, I met a contemporary woman (rather 4 years junior) in Imphal, who has had bilateral total-knee replacements because of OA. When I met her one year earlier, I recommended total-knee replacements for her severe osteoarthritis, which must have affected her mood and outlook on life, though she didn’t show it.
I was awe-struck finding this lady with OA. She gave me a preposterous leap of faith in OA, which was very uncommon in Manipur, during my short medical practice in Imphal. It might be due to the fact that many Manipuris didn’t
live long enough to have the disease. They were not overweight and had no occupation that would overload their weight-bearing joints. Also Manipuri life-style is mostly sitting down, such as cooking, weaving. OA has strong genetic and occupational components, more common among strenuous manual workers, such as heavy lifting, bending and carrying.
This pretty lady was one of a handful of beautiful girls of my youth. Though her wrinkle-free face remained almost untouched by the ravages of time, her knees took the full brunt of fluctuation-dissipation of an ageing process. Her slim body and comely face belied her age. As I remember, there is no history of OA in her aristocratic family. She was the last person I expected to be having such a severe form of the disease.
The disease itself gave me a kick in my teeth. Until I retired 8 years ago (I do keep in touch with modern advances in medicine), OA was considered a ‘wear and tear’ disease of joint cartilages and bones, and not due to inflammation (body’s response to injury, infection etc.) Osteoarthritis (osteo = bone; arthritis = inflammation of joint) was considered a misnomer. The diagnostic criteria have now turned around. ‘Wear and tear’ is the wrong name. This came about in November 2011, when American researches from Stanford University School of Medicine, published papers in Nature Medicine that
examination of synovial fluid in osteoarthritic knees, demonstrated abundant evidence of inflammation, just not the wear and tear of cartilages and bines, but rather, an abnormal modelling of joint tissues driven by a host of inflammatory mediators within the affected joint. It’s not an inevitable part of old age.
OA begins as wear and tear because of injury, excessive carrying of load, hereditary, and old age, as they potentiate cartilage damage, but its progression is the result of inflammation. Nonetheless, the exact biological mechanism that causes and sustains OA remains unknown as yet.
The American College of Rheumatology has specific criteria to make the diagnosis. They call it the “tree format”. And the idea of treatment of osteoarthritis has really been replaced with the notion that it is a disease to be managed with different approaches. That means, there isn’t one single treatment for everyone. However, when severe symptoms with reduced function of the knee have substantial impact on the quality of life , total knee replacement (TKR) surgery is indicated.
Over the past 50 years TKR surgery has been evolving and now there over 150 replacement designs (prosthesis) on the market. The revolution of surgical technique using robots is rather recent. TKR surgery was performed in 1968 in America. The procedure has now a high success rate and is considered relatively safe and effective. The average age of recipients is 70, and about 60% are women. Patients can carry on normal activities after 6-12 weeks.
First TKR surgery in India, was performed in 1987 in Delhi, by Ashoka Rajgopal, considered the best orthopaedic surgeon in India. The first total hip replacement surgery using a metallic prosthesis (now known as Austin Moore prosthesis) was done in 1940 by Dr Austin Moore in South Carolina, US. It became popular world-wide in 1960s. In India, it was first performed in 1970. In early 1980, I had one AM prosthesis, made of lighter titanium, sent from Delhi for my eldest sister-in-law Ibemhal. It was fitted in Imphal by a Meitei orthopaedic surgeon. It lasted over 10 years until she died.
TKR is now being perfected by some surgeons using robots for clinical efficiency and improved patient wellbeing. According to Mr Simon Jennings, Deputy Clinical Director, Orthopaedics, Lead for Orthopaedic Enhanced Recovery, London North West Hospitals, Robotics are making knee surgery more accurate and cost effective. He says, “Robot-assisted surgery though it may seem futuristic, is already making a huge difference for total knee replacements. The technology works by first enabling the surgeon to build – in real time – a three dimensional image of the knee via sensors attached to the thigh and shin bones. Surgeons are able to build an accurate blueprint of the knee and the leg’s alignment, as well as plan their course of action.”
“On the computer, during the operation, I create a patient-specific plan. I’ve mapped out the knee, I’ve worked out what sizes of implants I need. I position them on the model to work out the perfect position and shape to restore the patient’s anatomy and functional range. of movements.” “The clever bit at the end of it and the more robotic part, is the handpiece – a computer-controlled, high-speed burr that cuts exactly and only where I have planned on the knee model I created.”
Further, that level of accuracy allows surgeons to replicate exactly what they’ve planned, which was impossible to achieve when using only the naked eye. Improvement in the accuracy of implant placement has allowed patients to get up and out much sooner, and the knee should feel normal a bit quicker. It will further improve the longevity of implants. The robotic system will cut exactly what is needed to cut, without trays of instruments, in order to fit all shapes and sizes, Mr Jennings continues.
Mr Mathew Bartlett, Consultant Orthopaedic Surgeon, London North West Hospitals, says, robotic surgery knee implants, in time, would make patients feel far more like a normal knee, with greater functional range. The aim is for patients to forget that they have had a knee replacement. They will have quicker recovery times and long-term mobility. Using the robotic hand piece means less invasive surgery, less bleeding, reducing swelling and stiffness. It will reduce the use of a CT scan for planning and thus less radiation to the patient. On the whole patients should have a brighter long-term outlook.
Professor David Barrett, Senior specialist knee surgeon, Southampton University, UK, says: “We are employing the software used to design cars and aircrafts to design knee implants and predict how the human body will respond to them.” Traditionally, arthritis was mainly disease for the elderly. Now, the patients are getting younger, partly due to sports-related injuries and partly because people are heavier. But it’s also because patients have become more demanding. Previously, people with knee issues would simply accept reduced mobility. The new breed of patients won’t do that. They want to play golf and tennis in their retirement, says Barrett. What we can show is that a properly prepared and relaxed patient enjoys a quicker recovery time and a much better outcome.”
The first robotic-assisted TKR was performed in Pune, India by Dr Narendra Vaidya at Lokmanya Hospital in July 2017, in the presence of an American-based Indian surgeon Vivek Neghinal. It’s a coincidence, but the current understanding of OA fits hand in glove, with the Meitei patient mentioned above. All being said, robot- assisted TKR will take time to establish in India.
The writer is based in the UK. Email: irengbammsingh@gmail.com website: www. drimsingh.co.uk

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