ΡΟΜΠΟΤΙΚΑ ΥΠΟΒΟΗΘΟΥΜΕΝΗ ΟΛΙΚΗ ΑΡΘΡΟΠΛΑΣΤΙΚΗ ΓΟΝΑΤΟΣ
DESCRIPTION
(Παρουσίαση στο Πανευρωπαϊκό Συνέδριο Ορθοπαιδικής Χειρουργικής & Τραυματιολογίας, Μαδρίτη/ Ισπανία 2010). PASSIVE ROBOTICS IN TOTAL KNEE ARTHROPLASTY. PRELIMINRY RESULTS. EFFORT CONGRESS, MADRID/SPAIN 2010TRANSCRIPT
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S.ALEVROGIANNIS, MD, PhD.CONSULTANT ORTHOPAEDIC SURGEON
2ND Orth. Dept.251 General Air Force Hospital, Athens/GR.
G. A. SKARPAS, MSc, PhD8TH Orth. Dept., General Hospital “Askepieion Voulas”, Athens-GR.
11th EFORT CONGRESS MADRIT 2010
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• 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
Knee Pain Patient Population: Underserved and Growing
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• Patient – Centric Healthcare Increase in Internet education Increase in Direct to Consumer
Marketing Patients desire superior high
tech CAOS/ Robotic Solutions
• Early outcomes Robotic Surgery Improved accuracy Repeatability Enabling: minimally
invasive surgery Next frontier is
orthopedics
Major Healthcare Trends
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© MAKO Surgical Corp. 2009
Patients Desires in Knee Surgery
No Lifestyle Change
Latest Technology
No Hospitalization- Short Rehab
No pain
Long Term Solutions
AAOSSurvey
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TKA Gold Standard For Surgeons
• 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 .
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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
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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
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AIM OF THE STUDY
To present our preliminary results, using Navigation for TKR.
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EARLY NAVIGATION SYSTEMS
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WHAT IS CAS ?
A NEW TECHNIQUE:
Navigation Passive Robotics Joint Surgery Bridging the gap between
TKR and technology Bringing More Treatment
Options
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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.
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ΤΕCHNIQUECAS 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.
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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.
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ΤΕCHNIQUESurgical 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.
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ΤΕCHNIQUE
Every 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 patient's 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.
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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 ranges.
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PROSTHESES
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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
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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.
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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.
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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.
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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.
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Material
35 patients (35 knees) Mean age 73 years (60 – 82) W: 23, M : 12 KNEES: L:15/R:20 Mean height 167cm ΒΜΙ: 34 ( 61% OVERWEIGHT) 1ST TKR FOLLOW UP: 1 year PRE-OP score KSS: 40+13(26-53)
KNEES
RIGHT
20LEFT15
ΦΥΛΟ
MEN
12
WOMEN
23
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Aetiology for operation ΟΑ:30 RΑ:2Post.Traumatic:2 PVNS:1
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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
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OPERATIVE PLANNING VIA NAVIGATOR-assembling the sensors
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PRE-OP MEASUREMENT
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TIBIA
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TIBIA
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FEMUR
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FEMUR
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FEMUR
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FEMUR
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IMPLANT CHECK
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FINAL ALIGNMENT
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FINAL RESULT
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POST-OP X-RAY
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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 )
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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.
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KNEE FUNCTION
KNEE FLEXION
PATIENT PRE-OP920( 70-1150)
Pt POST-OP1080 (80-1250)
< 700 3 _
70-890 15 _
90-1080 14 11
> 1100 3 24
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KNEE FUNCTIONCLIMBING STAIRS PTs PRE-OP PTs POST-OP
NORMAL 3 25
CLIMBING UP NORMAL- CLIMBING DOWN WITH HELP
7 8
CLIMBING UP AND DOWN WITH HELP
15 2
CLIMBING UP WITH HELP- CLIMBING DOWN IMPOSSIBLE
8 -
TOTAL IN COMPETENCE 2 -
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KNEE FUNCTION
WALKING PTs PRE-OP PTs POST-OP
ONLY AT HOME 19
< 10 BLOCKS 7 5
> 10 BLOCKS 9 8
WITHOUT LIMITATION
0 22
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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-op
Severe pain 69,2%/ Moderate 21%/ Mild 5,6%/ No pain 4,2%
Post-op
Painless 68,7%/ Mod 6.55%/ Mild 24.3%
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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%
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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.
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THANK YOU