Knee Replacement Surgery using Robotic Technology

Knee Replacement surgery using Robotic Technology

A talk with Dr. Mukesh Laddha

Speaker: Mr. Vivek
[0:00]

Hello, welcome to Dr. Talks. Here we chat with best doctors about diseases and conditions they treat. Our guest today is Dr. Mukesh Laddha. He is one of the top orthopedic specialists in India. He heads the center for robotic joint replacement and sports medicine in Nagpur. Dr. Mukesh is pioneering the use of robotic technology in joint replacement. Welcome Dr. Mukesh.

Speaker: Dr. Mukesh
[0:31]

Hello Mr. Vivek. Thank you for inviting me. I am highly obliged.

Speaker: Mr. Vivek
[0:35]

I would request you to share your background in medicine with us.

Speaker: Dr. Mukesh
[0:41]

Hi, I Dr. Mukesh Laddha, shoulder, knee and hip surgeon, robotic joint replacement arthroscopy and sports medicine specialist practicing in Nagpur city, which is centrally located in India. After my basic education in orthopedic training, I trained myself at various centers in India and abroad in the field of arthroscopy and joint replacement. In India I got trained myself in Mumbai, Cochin, Coimbatore and abroad I went to Japan, UK, and London to train myself in the field of arthroscopy, sports medicine, and in joint replacement surgeries. Since the last 10 years, I have been into private practice in Nagpur treating shoulder and knee joint pathologies related to sports injuries, ligament injuries, rotator cuff injuries and replacements of shoulder knee and hip joint. I am the only surgeon in central India doing robotic assisted total and partial knee replacement surgeries.

Speaker: Mr. Vivek
[01:44]

Thank you, doctor. Today, I wanted to discuss about knee replacement surgery with you. But before that, I would like to share a few interesting facts with our listeners. Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. According to the Agency for Healthcare Research and Quality, more than six lakhs (600,000) Knee replacements are performed each year in the United States. While as per some estimates, India will see nearly 1 million Knee replacements every year by 2022. Coming back to our discussion, can you please explain what knee arthritis and its types.

Speaker: Dr. Mukesh
[02:39]

Basically, there are two types of Knee arthritis which is commonly observed. The first is called primary osteoarthritis, which everyone will have in the world in some form or the other as the age increases the cartilage of the joints shows wear and tear each and every joint of the body will be affected. But the knee joint is most affected because it’s the weight bearing joint. This is called primary osteoarthritis. There is another form of arthritis which is quite common worldwide is called rheumatoid arthritis. This is an inflammatory form of arthritis, which can happen in early age called juvenile rheumatoid arthritis or sometimes it occurs in elderly population also. In this, it affects mainly the small joints of the hand, the wrist joint. hip as well as the knee joints and another 2% to 3% that are another form of osteoarthritis secondary to other inflammatory procedure problems. The most common are two forms primary osteoarthritis and secondary rheumatoid arthritis.

Speaker: Mr. Vivek
[03:55]

Who is commonly affected by Knee arthritis?

Speaker: Dr. Mukesh
[03:59]

As I mentioned in my previous answer, primary osteoarthritis usually occurs in elderly patients, females, usually after menopause about 45 to 55 years, and men, usually after 65 to 70 years are affected with primary osteoarthritis. If a patient is suffering from rheumatoid arthritis, then they may be as young as 20 to 21 years also.

Speaker: Mr. Vivek
[04:24]

Okay, so the patient as young as 20 to 21 years can get Knee arthritis, right?

Speaker: Dr. Mukesh
[04:30]

Yeah. But provided they have an inflammatory form of arthritis called rheumatoid arthritis.

Speaker: Mr. Vivek
[04:36]

And what’s the trigger for that kind of arthritis? Is it because of genetics or it’s because of lifestyle?

Speaker: Dr. Mukesh
[04:42]

No, mainly rheumatoid arthritis is genetically motivated. But there are multiple reasons for primary osteoarthritis. Age is the one of the biggest factors. Second, your eating habits lead to obesity. In the current era obesity is one of the major factors which put excessive weight on your knee joint, thereby causing its wear and tear early age.

Speaker: Mr. Vivek
[05:10]

What are the treatment options for knee arthritis? Can you describe both medicines based or non-surgical and surgical options for treatment?

Speaker: Dr. Mukesh
[05:21]

So, let me divide it into two as we have divided the type of osteoarthritis. So first I will discuss the most common form that is primary osteoarthritis. This usually occurs in the older population about 50 to 55 years, so no one can run away from this osteoarthritis. But if you take care of your body well from your younger age when you are in youth, do regular exercises, keep your body weight within limits, have good eating habits. Try to avoid junk food so that your overall body mechanism is quite better. Most important I would like to focus here on the importance of exercise and physiotherapy. Though it may not prevent you from developing osteoarthritis, if your muscles are quite flexible, the excess weight on the joint is a little bit less. So, it delays the onset of osteoarthritis and your exercise schedule should be quite perfect, at least five times. So that your bones are healthy enough, the nutrition to the joint is healthy enough and your proper eating habits will keep you overall as well as your joints healthy. So, these are some of the non-medical measurements in the form of exercise and physiotherapy. Once you start having pain, because of this osteoarthritis, then you need to consult your doctor which may give you some regenerative medicines in the early stage of osteoarthritis. Which helps to regenerate the cartilage at the molecular level. But they are helpful only if you diagnose it in early stages. So, some nutraceuticals are helpful. Painkillers are usually taken only when it affects you a lot. Then the third option is there are some intra articular injections which helps you increase the lubrication of your knee joint that has to be taken after consulting with your primary doctor. So, these are the medical and the non-medical treatments in the form of physiotherapy. Once you have utilized all these options of non-surgical management, and we’ve reached a stage where you feel the knee joint is hurting a lot, it’s affecting your activities of daily living, you are unable to drive your car, you are unable to walk for more than 500 meters, you are unable to go and enjoy parties with your friends or other social life activities then that is the stage we have reached a severe form of osteoarthritis and need to consult your doctor for knee replacement surgery. And the second thing about rheumatoid arthritis, it is altogether a different treatment most of the time and for a very long duration you have to take disease modifying drugs under the care of a proper orthopedic surgeon or rheumatology surgeon.

Speaker: Mr. Vivek
[08:27]

How do you diagnose that a particular patient has to go for a knee replacement surgery.

Speaker: Dr. Mukesh
[08:33]

For example a patient around 60 year female coming to my outpatient clinic complaining of pain for a long duration. You say that she has exhausted with all the non-surgical treatment for the way she walks which points knee becomes deformed. That’s the one sign which tells me that she needs knee replacement surgery, then we clinically examine the patient to see that she doesn’t have any problems in the hip joint , spine or in the ankle joint. We then check the amount of deformity she’s having the muscle power, the sensations and the deformity correction possible or not. After doing a thorough clinical examination we send them to do a proper X ray in the form of standing scanogram, single leg AP standing, lateral views x rays as well as skyline. So once we diagnose that she is a candidate for total knee replacement, we explain to the patient in detail about the procedure how it is done. And then you have to do some basic preoperative blood tests, the form of complete blood count, liver function tests, kidney function test, correlation profile. If the patient is diabetic, then you have to do the sugar tests, thyroid tests and urine examination, as well as being a very major surgery. We go for cardiac fitness also in the form of ECG and 2d Echo.

Speaker: Mr. Vivek
[10:30]

What would a patient expect during the procedure and after the procedures completed?

Speaker: Dr. Mukesh
[10:35]

The procedure goes this way. Once we get a complete fitness of the patient from a physician, because most of the old patients have some medical issues like diabetes, some patients have cardiac issues, some people have thyroid problems, once we get the proper fitness from a physician, controlling the blood pressure, sugar and we then ask the patient to get admitted a day before the procedure or the same day in the morning we asked them to be empty stomach for about six hours prior to surgery and our anaesthetist meet them and explain them the procedure of anaesthesia, which is usually a spinal if it’s a single leg operation or if we are doing both a knee replacement in one sitting, then it’s an combined anesthesia in form of epidural as well as spinal anaesthesia. And once a patient is explained about this, we take them to the operation theater, prepare and scrub. We do the procedure. I usually do all my knee replacement with the help of a robotics assistant and it takes hardly 60 to 70 minutes for the whole procedure. The patient is shifted to the recovery room where they take rest for a while. And as soon as the anaesthesia goes off, we start the physiotherapy four hours after the surgery in the form of knee bending, active leg raising etc. We make them stand and walk the same evening or the next day morning.

Speaker: Mr. Vivek
[12:10]

Doctor you mentioned about robotic surgery. Can you share more about how your center leverages robotic technology during knee replacement.

Speaker: Dr. Mukesh
[12:19]

If you see the knee replacement surgery started way back in, I think in around 1965 or1970. And from that time, significant development has been done to improve the outcome of the surgery. This knee replacement surgery is basically what we do in that we remove about say, eight to ten millimeter of the part of the bone, leg bone callus tibia, and the thigh bone callus fema and we replace it with a metal implant and a plastic implant between the two metals. Now, each and every individual have the same knee joint, which is formed by three bones fema thigh bone, PBR leg bone and the kneecap called as patella. But there are some definite angle difference, which is very specific to each individual, though the knee joint is formed by same bone, but the angle varies. So, conventionally replacement which has been done since long has shown excellent results in 80% of the population worldwide, and it is the statistical analysis all over the world that still around 20% of the patients who are undergoing total knee replacement are not happy. So, there were two factors, one related to the procedure, second related to the patient. One which is related to the patient should be that we should give them realistic expectation that out of the whole body we are replacing only one joint that is knee joint, which won’t make them younger but definitely will give them a significant amount of pain relief, good mobility and function but they shouldn’t expect that they should run and do other sorts of things. So, the expectation of the patient should be very realistic. Secondly, as I told you, each individual has a specific angle. So, all these specific angles are not possible for the naked eye to calculate. So, this robot helps me precise planning of each and every individual knee replacement. So, it is a customized knee replacement surgery. So, it helps me to make a precise cut in the patient’s bone which is quite normal or near normal to his body, so the knee replacement implant position is quite perfect. Secondly, knee replacement success depends on the ligaments, two main ligaments called as medial collateral ligament and lateral collateral. So in conventional, we don’t have any objective measurement to know how much a ligament we have to release and how much tight we have to keep it. And robotics gives me an objective number of how much I have to release so that that is specific for that patient. So in short, I will tell you in a layman language, if you have a size of your shirt, say 42 to 41 to be more precise if your shirt is 41 and if you go to a readymade garment shop, they will give you a size of 40 ,42 and 44. But they won’t give you 41. So, it’s only a tailor who can make a precise size of 41 for you, which will be exactly the same way my robot helps me to exactly plan. What is the ideal position of the knee implants for my patient and the amount of ligament balance. That is, the beauty of robotics.

Speaker: Mr. Vivek
[16:03]

The shirt analogy was a really great analogy doctor and can you share what difference you would have observed in the expectations or the results of your patient when you had treated them using robotic technology and when you’re treating them without robotic technology.

Speaker: Dr. Mukesh
[16:19]

Yeah, I have seen a significant difference in my own patient outcome. Earlier they used to complain of pain after surgery for seven to eight days. Now they complain of pain only for a day or two. So now the amount of painkillers have gone down drastically. They feel quite confident in getting out of the bed within 24 hours of the surgery because they feel that there is a natural knee despite an artificial knee. They have almost a full range of movement which they didn’t have before surgery, they’re going home even after both knee replacement walking without any support on the third day of surgery, the stair climbing is done within 48 hours of the surgery which patients are doing on their own. So the confidence level has grown up very fast and they feel like they have delayed the surgery because of the other parameters they have to decide for surgeries. So overall if I say the blood loss has reduced significantly, the precision of surgery has improved, surgical time is reduced. Patient confidence has gained, the bone loss is minimum, ligament balance is very precise. Patients do not need any extra physiotherapy in about 70% of the patients after robotic assisted knee replacement. They are fast to their activities of daily living within seven to eight days of surgeries and their activities of daily living like going outside and socializing within three weeks of surgery and without assistance. They are able to walk within 48 hours of surgery.

Speaker: Mr. Vivek
[18:11]

Great, and those are very wonderful results and just for the information of our listeners. Are there any associated risks of knee replacement surgery?

Speaker: Dr. Mukesh
[18:23]

Yeah, knee replacement surgery if you go there are a few risk factors and as I told you, these patient are elderly patients most of whom have some or other form of medical problems. So the common complications is what you find is DVT that is deep vein thrombosis. So, to prevent them, we start mobilizing the patient within four hours of the surgery. And if a patient is high risk for that, we start some blood thinning agents immediately after surgery. Secondly, there are chances of infection which is around 1% worldwide, there are some high risk patients like one who is on diabetes patient who are immunocompromised patients who already have previous surgeries on their knee, they are high risk, we have to take extra precaution in preventing them that is their sugar should be strictly controlled with a physician in house. And the rest of the things as I told you we mobilize them fast and we take care of it with antibiotics. The old age patients usually are osteoporotic. So chances of fractures are also there, these are all short term early, late or in delayed complications. You will see implants loosening, that is the failure of the processes if we don’t match the alignment and balancing of the knee. So with robotic alignment and balancing is quite perfect. So the knee replace procedure may last more than 15 to 20 years. Another minor complications of some allergy, some swelling on the foot, some stiffness post-operative, which is there, which is taken care very well with physiotherapy and other medicines.

Speaker: Mr. Vivek
[20:15]

I was reading an article about knee replacement and it stated that the success rate for knee replacement is higher than 95% while the majority of artificial knees implanted continue to be in working mode, even after 15 years, is this correct doctor?

Speaker: Dr. Mukesh
[20:38]

Totally correct. As I told you, the success rate is more than 98% but the satisfaction rate was around 80% because of the various issues with the patient satisfaction and the component placement in ligament balance, so to improve the satisfaction rate of the patient conventional was replaced by computer navigation surgery and above computer navigation now we have a robotic assisted knee replacement surgery. And if you follow and you see the results, even the 15 year success was there with the conventional surgery. So to improve that 15 years, they have come out with robotics so that we are aiming for a patient who needs only one surgery of knee replacement in his lifetime. If a patient comes to me around 60 to 65 years of age, and if I can give him a knee replacement for up to 25 years, that is till he becomes 90 so he can have only one surgery in life.

Speaker: Mr. Vivek
[21:44]

I understand you undertake various activities to support weaker sections of society. Can you please elaborate your efforts to support patients?

Speaker: Dr. Mukesh
[21:58]

There are various activities which we take to support the patient. First, we have a patient education program through our various websites, our YouTube channel. Where we have been educating them about how to delay knee replacements surgery. So that the later they come to us, they need one if suppose someone comes to me at 50 to 55, their high demand patient, they have a lot of activities. So even if I do a good job, it won’t last more than 15 to 20 years, because they are quite active patients. And the same patient if it comes to me at the age of 65 or 70, their activity levels are less, so the success will last longer. So we try and encourage and help educate a patient on how to delay. Secondly, if someone needs knee replacement surgery, in spite of all this and they’re quite weaker financially, then we as a hospital take a combined decision of doing it at no profit, no loss basis for a monthly four to five surgeries. So we categorize our department so there are some people who are working with us, they take care of these things, categorize them, and give them concessions whenever they need. And we have some NGOs, who help us in treating patients from weaker section.

Speaker: Mr. Vivek
[23:26]

That’s a really nice initiative from your side, Dr. Mukesh. And today your inputs helped us understand about knee arthritis and both surgical and non- surgical treatment approaches. We also learned about knee replacement surgery by leveraging robotic technology and its benefits. Thank you for talking to us.

Speaker: Dr. Mukesh
[23:50]

It was indeed a pleasure for me to have been invited by you on Dr. Talks. Thanks a lot.

Speaker: Mr. Vivek
[23:57]

Dear listeners, please share and spread awareness about Arthritis and its treatment by sharing this podcast. Cheers. Till we meet next time.