Hospital for Special Surgery (HSS) and Chairman of the Complex Case Review Panel at Hospital for Special Surgery

Advances in technology, surgical technique and implant design aim to optimize outcomes in joint replacement surgery. Many believe these innovations could lead to a knee or hip replacement that lasts a lifetime, even in younger patients. Although it will take time for patient registries and other forms of data collection to substantiate that view, the pinpoint accuracy of robotic-assisted surgery, newer types of prostheses and other advancements could make it possible.

Robotic-Assisted Joint Replacement

The use of robotic-assisted joint replacement with computer navigation is growing rapidly as increasing numbers of hospitals acquire the technology. The robotic systems allow for the optimal alignment, soft tissue balancing and positioning of the implant – critical to the success of joint replacement surgery.

Medical device companies have brought various robotic systems to market. At Hospital for Special Surgery (HSS), many joint replacement surgeons use the Mako image-based robot when performing hip replacement, total knee replacement or partial knee replacement surgery. A preoperative CT scan provides a 3D model of the joint, which enables the orthopedic surgeon to determine the exact size of the prosthesis, alignment and positioning even before entering the operating room.

During surgery, the computer provides real-time data that allows us to assess the movement and tension of the new joint and adjust it as needed. A robotic arm controlled by the surgeon removes arthritic bone and cartilage, providing tactile resistance to help the surgeon stay within the boundaries defined in the surgical plan.

The unmatched accuracy of robotic-assisted surgery offers the additional benefit of protecting the soft tissues in the joint. We find that patients generally experience less post-operative pain and a reduced need for narcotic pain medication. They commonly reach physical therapy milestones more quickly and experience a faster recovery.

As for a surgical team’s learning curve when implementing robotics, studies have shown that while additional time may be needed to perform the surgery, especially in the beginning, the system is highly accurate, even when used for the first few cases. Today most major residency and fellowship programs are training future orthopedic surgeons with the robotic system. At HSS, residents and fellows appreciate its value and want to make sure they have access to the system after they complete training and enter orthopedic practice.

"Robotics and computer navigation increase accuracy, but don’t forget the personal touch"

The main barrier to adopting robotic-assisted technology is the cost. Many smaller hospitals and ambulatory surgery centers don’t have the financial resources to buy a robotic system with a price tag upwards of $800,000.

Advances in Prosthetic Design

For younger people seeking pain relief and a return to certain activities, implant longevity is a major consideration. Indeed, the number of individuals in their 50s or even late 40s seeking joint replacement to remain active has been on the upswing over the past decade.

The cementless knee replacement is an innovation that could enable a new joint to last longer. In a standard cemented knee replacement, the components of the implant are secured in the joint using bone cement. It’s a tried-and-true technique that has worked well for decades. But eventually, over time, the cement may start to loosen from the bone and/or the prosthesis. With the newer uncemented implant, the components are press fit into place for ‘biologic fixation,’ which basically means that the bone will grow into the prosthesis.

In the realm of hip replacement, the “dual mobility” prosthesis could be a good option for younger or more active patients who put more demands on their new joint. Several studies at HSS have shown that the implant lowers the risk for dislocation, one of the most common complications after total hip replacement, thus reducing the need for a revision surgery.

The dual moility system was designed to increase impingement-free range of motion and decrease dislocation risk by increasing the size of the femoral head component. This leads to a hip replacement with increased stability, which is especially important for patients who enjoy a very active lifestyle.

Not long ago, outpatient knee replacement would have been unheard of. These days, it is becoming more common thanks to less invasive, robotic-assisted surgery with less trauma to soft tissues; advances in the use of regional anesthesia; and multimodal pain management, which uses drugs that target different pain pathways, reducing the need for opioids. Candidates for an outpatient procedure have the joint replacement early in the morning and go home the same evening. They have the option to stay overnight if they are not ready to go home.

Putting the Patient First

While hospitals seek to remain competitive with the latest technology, providers must never lose sight of patient-centered care. The needs, goals and values of patients must play a key role in health care decisions.

At HSS, evidence-based care, including tech advances, aim to optimize outcomes. But it doesn’t stop there. A culture of collaboration, teamwork, and pride; careful coordination of care; maintenance of the highest safety standards; appropriate follow up; and real concern for the patient all play a role in achieving the best outcomes.

Many hospital systems are increasing their focus on patient satisfaction. They are distributing surveys and posting physician ratings on hospital websites, and with good reason. The relationship between the caregiver and patient will always be fundamental.

At the end of the day, a robot is, well, a robot. The latest and greatest technology will never replace respectful and compassionate care.