11 Aug 2020

ROBOTIC HIP REPLACEMENT SURGERY: gaining newer heights in hip pain relief

Kayal Orthopaedic Center

1. OSTEOARTHRITIS IS THE MOST COMMON CAUSE OF HIP PAIN IN PEOPLE OVER 50 YEARS OF AGE AND A PREDOMINANT REASON FOR TOTAL HIP REPLACEMENT (THR) SURGERY
2. IT IS ESTIMATED THAT APPROXIMATELY 40 MILLION PEOPLE SUFFERS FROM HIP PAIN AT ANY TIME DURING THE YEAR IN U.S., ABOUT 13% OF THE POPULATION, WHICH END-UP IN 300.000 CASES OF HIP REPLACEMENT SURGERIES PER YEAR.
3. THE MAKO ROBOTIC ARM ASSISTS SURGEONS PERFORM COMPLEX HIP AND KNEE SURGERIES WHERE PATIENTS FEEL LESS PAIN, HAVE QUICKER RECOVERY, GAIN BETTER MOTION AND FUNCTION, AND OVER TIME HAVE FEWER REVISIONS THAN STANDARD HIP AND KNEE REPLACEMENT SURGERIES.
4. THE BENEFITS OF USING THE MAKO ROBOTIC-ARM INCLUDES FEWER COMPLICATIONS, LESS PAIN AND FASTER RECOVERY TIMES, RESTORING CONFIDENCE IN YOUR MOBILITY AND HELPING YOU TO RETURN TO YOUR ACTIVE LIFESTYLE SOONER. THE LIFESPAN OF YOUR IMPLANT SHOULD ALSO BE INCREASED AS MORE ACCURATELY POSITIONED IMPLANTS LAST LONGER.
5. PEOPLE ELIGIBLE FOR THIS SURGERY HAVE MODERATE TO SEVERE ARTHRITIS IN THE HIP INCLUDING OSTEOARTHRITIS, RHEUMATOID ARTHRITIS OR POST-TRAUMATIC ARTHRITIS—THAT CAUSES PAIN AND/OR INTERFERES WITH ACTIVITIES OF DAILY LIVING

With technology reaching newer heights every day and the fine precision with which robots work, the potential for use of robots in modern surgery has ever been so increasing. Robotic surgery has been around for a while with robots being used in the field of general surgery, cardiology, obstetrics and gynecology and ophthalmology. However, advancements in robotic surgery has now quickly gained newer heights in the field of orthopaedics. The innovated technology of Robotic surgery (a minimally invasive procedure) is typified by the  Mako Robotic-Arm Assisted Surgical System, which allows for a much more accurate placement of your implants compared to more traditional joint replacement methods, meaning that you will have a more natural feeling joint post-op. The benefits of using the Mako includes fewer complications, less pain and faster recovery times, restoring confidence in your mobility and helping you to return to your active lifestyle sooner. The lifespan of your implant should also be increased as more accurately positioned implants last longer.

Causes of hip pain.

Osteoarthritis is the most common cause of hip pain in people over 50 years of age and a predominant reason for total hip replacement (THR) surgery(1) Hip pain is not always due to osteoarthritis. It is common cause in elderly people, however. It is estimated that approximately 40 million people suffer from hip pain, about 13% of the population which end-up in 300.000 cases of hip replacement surgeries per year. Hip pain may arise due to   traumatic arthritis, or avascular necrosis or other pathologies from joint itself or it may be due to referred pain from back too. Intra-articular pathologies like labral tears, loose bodies, impingement between femur and acetabulum, articular cartilage damage may give rise to pain apart from osteoarthritis. Similarly, structures outside the joint can be abnormal and give rise to pain. Pathologies like fractures, muscle strains, bursitis, piriformis syndrome, etc. needs to be ruled out.

Are you a candidate for Robotic Surgery?

There are no absolute age or weight restrictions for total hip replacements. Recommendations for surgery are based on a patient’s pain and disability, not age. People eligible for this surgery have moderate to severe arthritis in the hip—including osteoarthritis, rheumatoid arthritis or post-traumatic arthritis—that causes pain and/or interferes with activities of daily living. For example:

1. Walking, going up stairs, and bending to get in and out of chairs is difficult.
2. Pain is moderate to severe even while resting, and may affect sleep.
3. Joint degeneration has caused stiffness that affects the hip’s range of motion during normal activities. The person may have a limp.

Symptoms are not adequately alleviated by non-surgical treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, steroid injections, or the use of a cane or walker.

About 90% of people who undergo hip replacement have osteoarthritis. In addition to arthritis, some people have hip replacement surgery to correct problems related to broken bones or other medical conditions, such as osteonecrosis (bone death caused by inadequate blood supply). Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually.

If your suffering for severe hip pain or stiffness resulting from: noninflammatory degenerative joint disease (including osteoarthritis, traumatic arthritis, or avascular necrosis), rheumatoid arthritis or post-traumatic arthritis, You are a good candidate.

Minimally Invasive MAKO Robotic-Assisted Outpatient Hip & Knee Joint Replacement Surgeries are performed by Robert A. Kayal, M.D., our Chief of Orthopaedic Surgery at Kayal Orthopaedic Center.

Robotic surgery in hip replacement surgery…personalized surgery

During hip replacement, diseased parts of the hip joint are removed and are replaced by artificial implants- a metallic cup to cover the acetabulum surface and a metallic femoral component.

Hip replacement surgery is the only effective treatment for patients with severe hip pain or stiffness resulting from various degenerative diseases like osteoarthritis, avascular necrosis of femoral head or traumatic injuries and other chronic diseases like rheumatoid arthritis; especially those for where conservative treatments have shown to be sub-optimal.

Robotic hip replacement is similar to normal hip replacement except that a robot is used to make component positioning more accurate by replacing hand-held reamers and mallet-driven broaches with CT-scan mapped programmed robots. The Mako Robotic Surgical System  allows for a much more accurate placement of your implants compared to more traditional joint replacement methods, meaning that you will have a more natural feeling joint post-op. The benefits of using the Mako includes fewer complications, less pain and faster recovery times, restoring confidence in your mobility and helping you to return to your active lifestyle sooner. The lifespan of your implant should also be increased as more accurately positioned implants last longer.

What the benefits of Robotic Surgery?

There are numerous benefits with robotic surgery, to mention a few:

1. Less pain and bleeding.
2. Surgery usually takes 1-2 hours.
3. Decreased pain and postoperative swelling.
4. Increased knee flexion movement immediately after surgery.
5. 1-2 day stay in hospital and a quick recovery. Sometimes same day procedure
6. Fewer complications, such as surgical site infection.
7. Smaller, and less noticeable scars.
8. Less soft tissue and ligament injury.
9. You Will be able to put full weight on your leg on the day surgery.
10. Implant  that’s very custom  to each individual patient, with a better longevity.
11. Improved stability
12. Return to doing the activities joint pain has prevented you from doing. Quality of life

How is the operation planned?

Prior to surgery, a CT scan of your hip joint is taken in order to generate a 3D virtual model of your unique anatomy. The 3D model helps your doctor see things he or she can’t typically see with an x-ray alone. This additional information helps your doctor determine the optimal size, placement and positioning of your implant. The amount of reaming and the accurate positioning of the components is planned based on CT scan data according to the patient’s own anatomy.After selecting proper prosthesis design, CT scan of the hip is done. The robotic system uses CT scan data to determine the femur size, shape and orientation and any limb length discrepancy if present; and also analyses the manufacturer’s data to describe prosthesis geometry.

How is the operation performed?

Instead of doing it freehand as in the conventional method, the acetabular socket is prepared and the acetabular component is placed by the robotic arm to ensure the pre-operative plan is followed as accurately as possible.

Robotic hip replacement is mostly similar to conventional hip replacement, but has few differences. Series of locator pins are placed at various positions in the hip which the robot uses to compute its position in the robot’s co-ordinate system and match the anatomy to the CT scan image. The robotic milling is then initiated while the surgeon monitors the progress both by direct vision and by watching the monitor.

What prosthesis are used?

There are no special prosthesis that are used in robotic hip replacement surgery. The same conventional prosthesis which has been commonly used for years are used.

Why it is better than the manual hip replacement surgery?

In the current manual procedure, the surgeon cuts the cavity by forcing handheld broaches and reamers into the femur, which leaves a rough and uneven surface. Until recently, the implant was cemented in place in this pocket, but long-term postoperative data indicated that the cement could crack, loosen, or cause bone destruction, leading to failure of the implant. Newer cement-less implants have a porous metal surface and rely on natural bone growth into the metal for-fixation. This ingrowth requires close proximity (0.25 mm or less) between the bone surface and the implant, so long-term success is highly dependent on a tight fit between the implant and the femur. The need for improved precision led to the creation of a robotic approach to forming the femoral cavity. However, only 38–47% of acetabular components are within the desired safe ranges of ante-version and inclination using these manual handheld techniques, and low surgeon volume has been identified as a risk factor for errors in implant positioning.(7) It is here that Mako Robotic Surgery makes the difference and creates a precise and smooth surface during the surgical process. The system provides two main advantages over the manual procedure. First, clinical trials have confirmed that the femoral pocket is more accurately formed. Second, because of the need to provide precise numerical instructions to the robot, preoperative CT images are used to plan the bone-milling procedure. This gives the surgeon an opportunity to optimize the implant size and placement for each patient. (6)These mentioned points translate into a more  accurate placement of the implant and a  better longevity. (9,10)

Robotic hip replacement allows for improved placement of components.(3) Robotic assisted hip replacement lead to improved patient-related outcomes and better patient satisfaction as judged from various scoring systems (e.g. UCLA score, WOMAC score, Modified Harris Hip Score).(2)

Following any hip replacement surgery, the functional outcome is affected by the accurate component placement and restoration of hip biomechanics.(2) Intra-operative blood loss is also significantly less in robotic hip surgery as compared to standard hip surgery.(2).

The main study comparing traditional surgery vs robotic surgery was done by Harvard University. The most importa points was placement accuracy of the implant. Traditional surgery was 50% compare to 100% for robotic surgery.

Intra-operative blood loss is also significantly less in robotic hip surgery as compared to standard hip surgery.(2) Hence, the robotic assisted technology offered better pre-operative planning and higher accuracy of the intra-operative procedure.(4)

Is it a less invasive procedure?

The critical question is whether robotic surgery’s technological advancements translate into better outcomes for patients. By using smaller incisions and instruments, any robotic surgery usually offers advantages over open surgery—including less blood loss, a lowered risk for infections, more accurate placement of the implant, and shorter hospital stays. The same approaches (cuts); posterior, anterior or lateral; used in the standard manual approach are used in robotic assisted hip replacement surgery.

Is it more accurate?

There are many research papers which showed better accuracy with component placement by robotic assisted surgery.(5) Hence, robotic hip replacement surgery has come up as a better substitute of the standard hip replacement procedure and has shown some promising results in the field of hip arthroplasty.(8)

What are the potential risks and complications of robotic surgery?

Like the traditional surgery complications are minimal but should be kept in mind.

Most common are:

1. bleeding or the need for transfusion.
2. risk of infections.
3. temporary nerve or intra-abdominal organ injuries.
4. breathing problems.
5. stroke, heart attack.
6. blood clots in the legs or reactions to medications.

Conclusion:

Osteoarthritis is the most common cause of hip pain in people over 50 years of age and a predominant reason for total hip replacement (THR) surgery. Mako Smart-Robotics is an innovative solution for many suffering from painful arthritis of the knee or hip. Mako uses a 3D CT-based planning software so your surgeon can know more about your anatomy to create a personalized joint replacement surgical plan; where patients feel less pain, have quicker recovery, gain better motion and function, and over time have fewer revisions than standard hip and knee replacement surgeries. The benefits of using the Mako includes fewer complications, less pain and faster recovery times, restoring confidence in your mobility and helping you to return to your active lifestyle sooner. The lifespan of your implant should also be increased as more accurately positioned implants last longer. People eligible for this surgery have moderate to severe arthritis in the hip—including osteoarthritis, rheumatoid arthritis or post-traumatic arthritis—that causes pain and/or interferes with activities of daily living. Minimally Invasive MAKO Robotic-Assisted Outpatient Hip & Knee Joint Replacement Surgeries are performed by Robert A. Kayal, M.D., FAAOS, FAAHKS, our Chief of Orthopaedic Surgery at Kayal Orthopaedic Center.

References:

1. Zacher J, Gursche AJBP, Rheumatology RC. ‘Hip’pain. 2003;17(1):71-85.

2. Bukowski BR, Anderson P, Khlopas A, Chughtai M, Mont MAJSti. Improved Functional Outcomes with Robotic Compared with Manual Total Hip Arthroplasty. 2016;29:303-8.

3. Domb BG, El Bitar YF, Sadik AY, Stake CE, Botser IBJCO, Research® R. Comparison of robotic-assisted and conventional acetabular cup placement in THA: a matched-pair controlled study. 2014;472(1):329-36.

4. Honl M, Dierk O, Gauck C, Carrero V, Lampe F, Dries S, et al. Comparison of robotic-assisted and manual implantation of a primary total hip replacement: a prospective study. 2003;85(8):1470-8.

5. Chen X, Xiong J, Wang P, Zhu S, Qi W, Peng H, et al. Robotic-assisted compared with conventional total hip arthroplasty: systematic review and meta-analysis. 2018;94(1112):335-41.

6.        Robert D. Howe and Yoky Matsuoka. Robotics for Surgery:

Division of Engineering and Applied Sciences, Harvard University.

7.     Meermans G, Doorn JV, Kats JJ. Restoration of the centre of rotation in primary total hip arthroplasty: the influence of acetabular floor depth and reaming technique. Bone Joint J 2016;98-B:1597–1603. 

8.       Babar Kayani,1 Sujith Konan, et al. The current role of robotics in total hip arthroplasty. EFORT Open Rev 2019;4:618-625. DOI: 10.1302/2058-5241.4.180088

9. Bukowski BR, Anderson P, Khlopas A, Chughtai M, Mont MA, Illgen RL Improved Functional Outcomes with Robotic Compared with Manual Total Hip Arthroplasty. Surg Technol Int. 2016 Oct 26;XXIX:303-308.

10. Benjamin G Domb 1, Jeffrey W Chen, Ajay C Lall, Itay Perets, David R Maldonado.Minimum 5-Year Outcomes of Robotic-assisted Primary Total Hip Arthroplasty With a Nested Comparison Against Manual Primary Total Hip Arthroplasty: A Propensity Score-Matched Study. J Am Acad Orthop Sur. 2020 Feb 25. doi: 10.5435/JAAOS-D-19-00328.