Robotic Total Knee Replacement

Learn about advanced robotic knee replacement surgery By Dr Daniel Meyerkort – Perth Orthopaedic & Sports Medicine Centre

What is ROSA / MAKO Robotic Total Knee Replacement

Total knee replacement involves a full replacement of both sides of the knee joint and it is a beneficial  operation for end stage knee arthritis. The ROSA & MAKO surgical robots can assist in accurate implant positioning, a short recovery and excellent functional results. The are semi active surgical robots, which aid the surgeon in performing accurate bony cuts for knee replacement. The surgeon is physically in charge and controls the robot while cutting. Both the ROSA & MAKO surgical robots have unique advantages and Dr Meyerkort is trained in, and uses both systems.

About Perth Orthopaedic & Sports Medicine Centre (POSM)

Perth Orthopaedic has been providing Elite Orthopaedic care to the community of Western Australia since 1988. It is the longest running and largest Orthopaedic practice in Perth. It has an established reputation for quality and compassionate care. Dr Meyerkort is a specialist surgeon and works at Perth Orthopaedic.

Is the time right for my ROSA / MAKO Robotic Total Knee replacement?

Only you can decide when the right time is for you to embark on a total knee replacement. Your knee will never be too worn nor will you be too old. Total Knee Replacement will always remain possible if your symptoms worsen. As a guide, many patients consider surgery when:

  • Pain is stopping them from enjoying their normal activities and recreation.
  • Pain is disrupting night sleep.
  • Knee function, as assessed by the Oxford Knee Score, is in the mid 20s or below.

How long will a Robotic Total Knee Replacement last?

A common misconception is that a total knee replacement will last 10 years before requiring revision. Most patients should expect 20-30 years of trouble free use from a knee replacement. Results from the Australian Joint Replacement Registry in 2017 show that 92% of knee replacements are functioning at 16 years follow up. Younger patients, while having a higher likelihood of revision surgery, still have an excellent 83% survival at 16 years. Implant survival by patient age at 16 years follow up is documented below:

  • < 55 years – 83%
  • 55-64 years – 89%
  • 65-74 years – 93%
  • > 75 years – 96%

The patient journey through Robotic Total Knee Replacement Surgery

High dose antibiotics are given to minimise the infection risk and the knee joint is exposed. Around 8 mm of bone is resected from the distal femur and proximal tibia to accommodate the knee replacement. The artificial joint involves a metal femur and tibia, which is fixed to the bone and an ultra hard wearing polyethylene bearing. The patella is selectively resurfaced with polyethylene. An anaesthetic nerve block and high volume local anaesthetic are used to make your recovery comfortable. Mobilisation with the physiotherapist commences with full weight bearing and movement of the knee on the day of surgery, and most patients remain in hospital for 2-3 nights. Driving can commence when you can safely perform an emergency stop, which is usually at 4-6 weeks following surgery. Surgical and anaesthetic techniques have led to a vastly improved patient experience, especially compared to 10-20 years ago. Most patients are happy by 6 weeks however, your best functional result can take 12 months.

Robotic vs. Computer Navigation vs. Conventional Knee Replacement

Both robotic and computer navigation allow for more accurate bony cuts than conventional knee replacement. Computer navigation has been shown to reduce the failure rate of knee replacements in patients under 65 years of age. Kinematic alignment and the virtual gap balanced technique can be used with the robotic technique or computer navigation.

Robotic Total Knee Replacement to aim for Kinematic Alignment

Kinematic alignment refers to implantation towards the natural alignment of the knee. The natural knee has an average of 3 degrees of tilt both on the femur and tibia. The Mayo Clinic published their 20 year data and reviewed all published data in 2017 showing no correlation between alignment and implant failure. This has lead to increased interest in implanting the knee towards the natural ‘kinematic’ alignment.

Virtual Gap Balancing & Robotic Total Knee Replacement

Gap balancing involves the linkage of the femoral and tibial bony cuts to optimise ligament tension within the knee. Virtual gap balancing allows the effects of all bony cuts to be seen before a single cut is made. This technique can be used with Robotics and Computer Navigation.

Risks of ROSA / MAKO Robotic Total Knee Replacement

The most common risk is with knee replacements is ongoing pain. 10-15% of patients experience mild pain or stiffness, yet despite this are still happy with their knee replacement. Ongoing pain, and limited function to the point of a patient regretting surgery, occurs in 1-2% of knee replacements and is a complex multifactorial issue. Other uncommon risks include:

  • Infection
  • Blood clots
  • Nerve/ blood vessel damage
  • Fracture
  • Dislocation/ Instability
  • Bleeding
  • Pain/ stiffness

An Overview of Total Knee Replacement from the American Academy of Hip and Knee Surgeons

Robotic Knee Replacement

Learn about the MAKO Total Knee System

The above link is a patient education resource about the MAKO Total Knee System from Stryker Medical Supplies. It includes video of the MAKO system in use.

Learn about the ROSA Total Knee System

The above link is an overview of the Rosa Total Knee System. A unique point of difference with the ROSA Total Knee is access to digitally optimised rehabilitation in partnership with Apple. MyMobility is app based rehabilitation provided through an iOS or Android device. Apple users have access to a complimentary use of an Apple watch to guide their rehabilitation after surgery.

FAQS

Is robotic knee replacement better?

Robotic surgery is a surgical aid to allow for accurate knee replacement surgery. The robotic systems available (MAKO / ROSA) are semi autonomous systems, meaning the surgeon is always in control of your surgery. Studies have shown that robotic assistance allows for precise bony cuts to allow accurate implant placement and low levels of soft tissue damage. Modern knee replacement has shown excellent results for improved function and pain relief after surgery. Currently, no high quality studies show that robotic knee replacement is clearly superior to conventional knee replacement surgery in terms of reducing implant failure or leading to superior functional results. This is relatively new technology with robotic assisted knee surgery being widely available in Australia since 2017. Similar to the modern safety features in your car (automatic braking, lane keep assist etc) robotic assisted surgery can be a safety aid to performing accurate surgery.

HOW MUCH DOES ROBOTIC KNEE REPLACEMENT COST?

The robotic system costs the hospital up to 1.5 million dollars. There is no cost passed on to the patient. Dr Meyerkort is a no gap provider for all health funds, meaning that Medicare and your private health insurance will cover the costs of surgery. Out of pocket costs may be charged by the anaesthetist, blood tests and hospital admission excess.

WHAT IS THE RECOVERY TIME FOR ROBOTIC KNEE REPLACEMENT SURGERY?

Most patients spend 3 – 4 days in hospital after robotic knee replacement surgery however if your pain is low and you prefer home this can be achieved earlier! Physiotherapy & muscle strengthening (prehab) before surgery is an excellent idea as it has been shown to reduce pain, length of stay and improve functional outcomes. Patients are fully weight bearing and start range of motion of the knee on the day after surgery. Most patients use crutches for the first 2 – 3 weeks post surgery. By 6 weeks after surgery most patients are returning to ‘normal’ life, work, driving etc. Your best recovery can take up to 12 months after surgery.

WHAT KNEE REPLACEMENT IS THE BEST?

There is no ‘best’ knee replacement as many have excellent long term results. The Australian Joint Replacement Registry captures this data and is is publicly available. You can talk to your surgeon about accessing this information. Dr Meyerkort uses prosthesis with excellent long term results.

IS ROBOTIC TOTAL KNEE REPLACEMENT COVERED BY MEDICARE / PRIVATE HEALTH INSURANCE

The cost of the surgical robot which is up to 1.5 million dollars is covered by Hollywood Private Hospital / SJOG Subiaco. No additional cost is passed on to the patient. Dr Meyerkort is a No Gap provider with all health funds. This means the cost of you knee replacement is covered by Medicare and your private health insurance. Out of pocket costs may be incurred for the anaesthetist, blood tests and hospital admission.

IS ROBOTIC KNEE REPLACEMENT SURGERY MINIMALLY INVASIVE?

Minimally invasive surgery has been trialed for knee replacement. It has lead to increased surgical difficulty and can compromise implant positioning. Robotic knee replacement is not minimally invasive as the knee is still opened as per a conventional knee replacement. Robotic knee replacement can lead to less soft tissue damage due to the haptic protection the robot provides. This allows the robot to cut bone but not soft tissue.

WHY DO DIFFERENT ROBOTIC SYSTEMS EXIST (MAKO / ROSA / NAVIO)

Robotic surgical aids are closed systems, meaning they are limited to the use of the company which supplies the prosthesis. The MAKO robot is for the Stryker Triathlon total knee and the ROSA is for the ZImmer Persona total knee. Each knee replacement has it’s potential advantages. Dr Meyerkort uses the MAKO for partial and total knee replacement and the ROSA for total knee replacement. Hollywood Hospital has access to both surgical robots.

WHAT CAN YOU DO AND NOT DO AFTER ROBOTIC TOTAL KNEE REPLACEMENT?

Physical activity is good after robotic total knee replacement and I encourage you to become physically active post knee replacement. Walking, hiking, swimming, bicycle riding, surfing, snow skiing, tennis and golf are all good activities after knee replacement. It is controversial whether high impact activities will lead to premature implant failure. It is probably safest to avoid high level participation in AFL, soccer, running etc.

DO YOU NEED TO DO PHYSIOTHERAPY AFTER ROBOTIC KNEE REPLACEMENT SURGERY?

Absolutely! Without good physiotherapy you are at risk of a less good result from knee replacement surgery. It is recommend to do Physiotherapy before surgery (prehab) as this has been shown to reduce length of stay, pain and improve functional outcome. Physiotherapy will start day 1 post surgery and the team will help to optimise your recovery

ARE K-MART BIKE PEDALS USEFUL AFTER ROBOTIC TOTAL KNEE REPLACEMENT?
A recent study from the Gold Coast showed patients who used the mini bike pedals in their rehab had less pain and a shorted length of stay. I recommend you bring a pair of mini bike pedals from K-mart to Hollywood Hospital, the Physiotherapist will integrate this into your rehab protocols.
HOW LONG DOES IT TAKE FOR A KNEE TO BEND AFTER ROBOTIC TOTAL KNEE REPLACEMENT?
It generally takes 7 – 10 days for your knee to have a range of motion between straight and 90 degrees. By 6 weeks most knees are bending freely and best bend can take up to 12 months.
CAN I KNEEL AFTER ROBOTIC KNEE REPLACEMENT
Kneeling will not damage your knee replacement but many patients do not like to kneel due to residual scar sensitivity after knee replacement.
WHAT HAPPENS IF YOU WAIT TOO LONG FOR KNEE REPLACEMENT
I recommend that you delay knee replacement until pain and dysfunction is interfering with you living a healthy, active life. Knee replacement can be done at any point in the future, no matter how badly worn your knee is and even into old age. Most patients know the time for surgery, when their ‘world is shrinking.’ Often patients tell me they are avoiding physical activity, walks, sport and are getting pain throughout the day and night. This is a good time to consider knee replacement surgery.
WHAT HAPPENS IF YOU DON’T GET KNEE REPLACEMENT
Many patients delay knee replacement and live a full, active life even without cartilage in their knee! If you are getting limited pain and still functioning well, you are best to delay your knee replacement surgery. Physiotherapy, muscle strengthening exercise and weight loss can all help you reduce your knee pain.
HOW CAN I FIX MY KNEE WITHOUT SURGERY?
Many non surgical treatments can improve your knee pain and functioning. Physiotherapy to learn muscle strengthening exercise and weight loss (if your BMI is greater than 28) should be the first treatment for most patients and can improve pain. Simple painkillers such as Paracetamol and anti inflammatories can be trialed. Injections such as PRP and artificial lubricant (Synvisc, monovisc) can give temporary relief. Stem cell treatment has not currently been shown to be effective for knee arthritis.

Clinic Locations

West Perth, Joondalup, Canningvale