ΡΟΜΠΟΤΙΚΑ ΥΠΟΒΟΗΘΟΥΜΕΝΗ ΟΛΙΚΗ ΑΡΘΡΟΠΛΑΣΤΙΚΗ ΓΟΝΑΤΟΣ

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(Παρουσίαση στο Πανευρωπαϊκό Συνέδριο Ορθοπαιδικής Χειρουργικής & Τραυματιολογίας, Μαδρίτη/ Ισπανία 2010). …

(Παρουσίαση στο Πανευρωπαϊκό Συνέδριο Ορθοπαιδικής Χειρουργικής & Τραυματιολογίας, Μαδρίτη/ Ισπανία 2010).

PASSIVE ROBOTICS IN TOTAL KNEE ARTHROPLASTY. PRELIMINRY RESULTS. EFFORT CONGRESS, MADRID/SPAIN 2010

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  • To begin with please allow me to share some demographic and economic facts for the present day. And because the discussion for financial values comes from the US mainly, I will start by mentioning a few things for this country, that for sure mirror the situation in the majority of the so called Western societies.
  • This new assessment is called the VOYAGER AND IT REALLY MAKES A SURGEONS LIFE EASIER.
  • And because our study concerns the TKRs, the software we used was uniquely designed for this purpose.
  • The reason I ‘m showing this figure to you is due to the fact that our main aim was to reduce time and naturally cost through accuracy and excellent operation planning. On the other hand this graph here demonstrates the necessary learning curve for anyone who wants to use this platform, and to tell the truth, the curve is relatively accurate.
  • The surgical sequencing concerning the steps of the operation is crucial and the platform provides us with the best solutions at any stage, by giving us the ability to re-verify and re-measure all aspects and values of the patient.
  • Getting the right values for the patients anatomy, via recognition of certain landmarks at the femur such as trochlea, MFC, LFC, INTERCONDYLAR NOTCH, and at the tibia such as the tibialcondyles.
  • Yellow line is the planned cut and the green is the actual position of the cutting guide.
  • Determination of the extra-rotation.
  • Distal cut.
  • Femoral sizing.

Transcript

  • 1. S.ALEVROGIANNIS, MD, PhD. CONSULTANT ORTHOPAEDIC SURGEON 2ND Orth. Dept.251 General Air Force Hospital, Athens/GR. G. A. SKARPAS, MSc, PhD 8TH Orth. Dept., General Hospital “Askepieion Voulas”, Athens-GR.11th EFORT CONGRESSMADRIT 2010
  • 2. Knee Pain Patient Population: Underserved andGrowing •The Population is Aging -Age 55+, peak knee pain candidates, will grow 3 times the average rate of the U.S. population -Reaching 96 million by 2020 •Obesity Rates are Rising -In 2000, 31% of the adult U.S. population had a BMI of 30 -Estimated rise to 40% by 2010
  • 3. Major Healthcare Trends•Patient – Centric Healthcare  Increase in Internet education  Increase in Direct to Consumer Marketing  Patients desire superior high tech CAOS/ Robotic Solutions•Early outcomes RoboticSurgery  Improved accuracy  Repeatability  Enabling: minimally invasive surgery  Next frontier is orthopedics
  • 4. Patients Desires in KneeSurgery  No Lifestyle Change  Latest Technology  No Hospitalization- Short Rehab AAOS  No pain Survey  Long Term Solutions © MAKO Surgical Corp. 2009
  • 5. TKA Gold Standard ForSurgeons • Total Knee Arthroplasty (TKA) considered Gold Standard for degenerative joint disease • John Insall, M.D. – Father of Modern TKA • Proven long term survivorship 90% out 15 years • One of the most successful procedures in modern medicine Limitations • Highly invasive • Requires extensive rehabilitation • Addresses late stage osteoarthritis (OA) • Often over utilized due to lack of equally successful / predictable alternatives, (UKA) • Aggressively removes healthy cartilage when treating early stage OA • Per Duke University Study: 88-92% of men and women respectively decline Total Knee / Hip Arthroplasty .
  • 6. Limitations of Instruments Improper cutting block pin to bone alignment Vibration of blade can cause deflection & skiving Learning curve with instrumentation Pins can be a stress riser to bone Intramedullary alignment guides (standard for femur) are invasive and can cause pulmonary emboli upon tourniquet release Extramedullary alignment relies on the palpation of bony landmarks underneath varying thicknesses of soft tissue Requires larger incisions
  • 7. TKA outcomes have been shown to be dependenton implant positioning and alignment With conventional techniques:  Limited preoperative planning (templates, x-ray)  Instrumentation does not provide consistent alignment  Instrument cutting guides do not always deliver precise resection (blade skiving)  Requires large, sufficient size incision to inserts jigs  Jigs require pinning, thus there is more bone disruption
  • 8. AIM OF THE STUDY To present our preliminary results, using Navigation for TKR.
  • 9. EARLY NAVIGATION SYSTEMS
  • 10. WHAT IS CAS ?A NEW TECHNIQUE: Navigation Passive Robotics Joint Surgery Bridging the gap between TKR and technology Bringing More Treatment Options
  • 11. Move to Kinematics Klee is the Software for evaluation of joint kinematics developed on the basis of surgeon’s requirements to help the surgeon to analyze laxity values during the standard kinematics evaluation which are performed several times during the surgical procedure. In particular Klee addresses the standard kinematics tests executed before and after arthroplasty interventions to evaluate parameters such as the anterior-posterior (AP), the rotational laxity, the internal/external (IE) and varus/valgus (VV), and let the surgeon to define , to acquire and investigate further references. Klee quantifies the kinematics parameters and displays the knee position when they are performed, and therefore supports the surgeon to reproduce more precisely the same kinematics tests before and after the reconstruction for interventions such as: ACL, TKR,THR.
  • 12. ΤΕCHNIQUE CAS surgery, made simple  VOYAGER platform combines surgeon’s experience with accuracy and visualization features of computer technology.  VOYAGER provides the surgeon with improved information of surgical tools position related to patient’s anatomy, in order to significantly decrease positioning errors and to obtain better long- term results.  The use of VOYAGER platform allows to reduce the learning curve of surgical interventions and to decrease surgical times.
  • 13. ΤΕCHNIQUE Simplicity is the key of success  Mirò is the software for total knee arthroplasty.  Even the surgical instrumentation has been designed focusing on accuracy and minimally invasive surgery.
  • 14. ΤΕCHNIQUE Surgical sequence:  This surgical sequence has been studied to obtain at once both the maximum precision and an easy recovering of any unsatisfactory situations.  The tibial resection gives the surgeon a good benchmark to perform the femoral cuts, and more room to operate in the femoral part.  To leave the chamfers as the last cuts, allows a much more precise measurement of the articular gap, and a much easier recutting, if any is needed.  A functional system of augmentations of the trial balance helps the surgeon to select the correct thickness of the insert.  At any stage, the surgeon may verify the articular alignment with a metal rod inserted in the proper eyelets present in most of the instrumentation parts.
  • 15. ΤΕCHNIQUEEvery patient is different The unique bone visualization method of VOYAGER, combines the enhanced information given by bone morphing and the registration speed of imageless navigation systems. Only few points are required to define patients’ specific anatomy, which is represented in a clear way to avoid any possible misleading information. In each step the congruency of the patients data are verified with the anatomical database of the system. Implant positioning can be planned considering the soft tissue envelope through the ligament balance screen. A well balanced knee means long term results and patients’ satisfaction.
  • 16. ΤΕCHNIQUE Accuracy  Particular attention was bend to the design of surgical instrumentation.  Only one hand is necessary to hold firmly the cutting guide in the exact position, while drilling for fixation.  During the positioning of the cutting guide the VOYAGER interface warns the surgeon with a red frame if it is exceeding the tolerance
  • 17. PROSTHESES
  • 18. PROSTHESESTrekking knee system includes: Τwo femoral components: CR component (Cruciate Rataining) which provides for the preservation of the posterior cruciate ligament and PS component (Posterior Stabilized) which instead provides for its removal Τwo tibial components for rotating and fixed inserts Τibial inserts for mobile plate and inserts for fixed plate Ρatellar components Both the femoral components CR and PS and the fixed and mobile tibial components are also available in the uncemented version, with a VPS (Vacuum Plasma Spray) treated TiCoat
  • 19. PROSTHESES The TREKKING mobile bearing tibial components are manufactured in a CoCrMo alloy by micro fusion and machining. The plate of the mobile model is mirror-polished to reduce the back-side wear and provided with a central hole to accommodate the UHMWPE insert peg. For a better anatomical congruency, the keel comes in five different sizes. The posterior plate slope is 0° and allows for a better insert mobility. The TREKKING MBH tibial plate system includes a 3 mm plate for considerable bone sparing. Moreover, a finite element method (FEM) has been used to design the keel in such a way that an optimal mechanical strength is ensured. Components are available in cemented and uncemented versions with a VPS treated (Vacuum Plasma Spray) TiCoat surface.
  • 20. PROSTHESES The TREKKING MBH System features a rotating insert in a mirror- polished tibial plate and an articular surface perfectly congruent with the corresponding surface on the femoral component. The Trekking mobile bearing knee system has three main advantages:• Reduced polyethylene wear, thanks to an optimised articular contact area.• Improved implant function: each movement is accommodated by a different joint. Moreover, each surface has been specifically designed for a dedicated movement, thus considerably improving both wear performance and joint function.• Tibial plate rotation is a less critical parameter, since optimal alignment can be naturally reached by the bearing. The mobile bearing knee system is indicated in relatively young and active patients with good ligaments.
  • 21. PROSTHESES The TREKKING CR cemented femoral component is manufactured in a CoCrMo alloy. It is a Posterior Cruciate retaining system and therefore indicated in patients with ligaments in good conditions. Components are available in cemented and uncemented versions with a VPS treated (Vacuum Plasma Spray) TiCoat.
  • 22. PROSTHESES The fixed TREKKING System provides for a technique to fix the insert to the tibial plate consisting in notches on the tibial component that fit with the stainless steel wire spring of the insert itself. This system, beside granting a perfect fixation of the two components, minimizes the backside wear of the polyethylene insert, that can be compared to the wear rate of the articular surface, as recognized by several scientific works.
  • 23. KNEES Material RIGHT 20 LEFT 15 35 patients (35 knees) Mean age 73 years (60 – 82) W: 23, M : 12 KNEES: L:15/R:20 ΦΥΛΟ Mean height 167cm MEN ΒΜΙ: 34 ( 61% OVERWEIGHT) 12 1ST TKR FOLLOW UP: 1 year PRE-OP score KSS: 40+13(26-53) WOMEN 23
  • 24. Aetiology for operation ΟΑ:30 RΑ:2Post.Traumatic:2 PVNS:1
  • 25. METHOD Same surgeon Standard anterior midline approach/medial parapatellar exposure of the joint Clean theater-vertical laminar airflow system Special cutting guides-templates, lateral release Antibiotics-Anticoagulants
  • 26. OPERATIVE PLANNING VIANAVIGATOR-assembling thesensors
  • 27. PRE-OP MEASUREMENT
  • 28. TIBIA
  • 29. TIBIA
  • 30. FEMUR
  • 31. FEMUR
  • 32. FEMUR
  • 33. FEMUR
  • 34. IMPLANT CHECK
  • 35. FINAL ALIGNMENT
  • 36. FINAL RESULT
  • 37. POST-OP X-RAY
  • 38. POST-OP  Cool Pads  Drain-autotransfusion for 2 days  Antibiotics -3 days  LMWH-35 days  Early Mobilization  FROM + Special Rehab. Protocol  PWB: 2nd post-op day  FWB: 30 days  Hospitalization :6 days(5– 10 )
  • 39. RESULTS No major complications were seen. Follow-up at 6 and 12 months post-op. No presence of radiolucent zones (very early). Special tests for flexion-pain-well being all excellent.
  • 40. KNEE FUNCTION KNEE PATIENT Pt POST-OPFLEXION PRE-OP 1080 (80-1250) 920( 70-1150)< 700 3 _70-890 15 _90-1080 14 11> 1100 3 24
  • 41. KNEE FUNCTIONCLIMBING STAIRS PTs PRE-OP PTs POST-OPNORMAL 3 25CLIMBING UP NORMAL- 7 8CLIMBING DOWN WITH HELPCLIMBING UP AND DOWN 15 2WITH HELPCLIMBING UP WITH HELP- 8 -CLIMBING DOWNIMPOSSIBLETOTAL IN COMPETENCE 2 -
  • 42. KNEE FUNCTIONWALKING PTs PRE-OP PTs POST-OPONLY AT HOME 19< 10 BLOCKS 7 5> 10 BLOCKS 9 8WITHOUT 0 22LIMITATION
  • 43. RESULTS KSS Score : 40 pre-op./ 70 at 6 m.p.o/ 95 at 12 m.p.o. Knee Sore : 35-67-98. Function score: 43-75-99. Knee Pain Score:Pre-opSevere pain 69,2%/ Moderate 21%/ Mild 5,6%/ No pain 4,2%Post-opPainless 68,7%/ Mod 6.55%/ Mild 24.3%
  • 44. Results  Caplan-Mayer Survey: All prostheses survived 1 year post-op uneventfully.  Tibio-femoral axis: 0-5 Valgus 52.4% 0-5 Varus 36.4%
  • 45. CONCLUSIONS Clinical and radiological results equal to international literature. The MIRO software is an innovative tool for computer assisted surgery. Navigation TKR by SAMO is time sparing and allows shorter learning curve. Only crucial measurements and values are evaluated during the procedure, anatomically. Less intraoperative bleeding and less risk for fat embolism-no intramedullary guides. There is always the option for conventional TKR. Minimal invasive-instrumentation of same mentality-same cutting block for both bones. For sure a greater number of cases and mid- and long-term follow up is needed in order to prove the efficacy of the method.
  • 46. THANK YOU