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Robotic-assisted knee replacement now available in WNY

Michael Mogavero, a principal at Lafayette High School, hurt his right knee on the job three years ago. He had trouble keeping up with his young and daughter until he became one of the first people in upstate New York to undergo a robotic-assisted full knee replacement earlier this year at Buffalo General Medical Center.

"I was sitting down a lot," Mogavero said. "I was tired, and had constant pain and swelling. I was taking a lot of Ibuprofen. With this new technology, I was up and walking the day of surgery."

Traditional knee surgery generally requires a hospital stay of two or three days, followed by several weeks at home or in a rehabilitation center, as well as physical therapy. Results are generally good but one in five patients continues to struggle with some form of discomfort, said Dr. Sridhar Rachala, who performed Mogavero's surgery.

Recovery time tends to be quicker, and results seem to be better, with the new procedure, Rachala said.

"This has the potential to change the game, which hasn't happened in many years in knee replacement," he said. "That's because we're saving soft tissue, there's more personalized joint alignment and more precision."

A Western New York doctor figures prominently into the last knee replacement advancement.

Dr. John Repicci – a dentist turned orthopedic surgeon, and former chief of orthopedic surgery at Kenmore Mercy Hospital – was a pioneer in the development of a partial knee implant procedure that carried his name. Kenmore Mercy was the first hospital in Western New York to introduce Mako Robotic-Arm Assisted Technology for partial knee replacement surgery in 2007. The hospital just added Styker's Mako full knee replacement technology and plans its first surgery later this month.

Rachala, and Drs. Matthew Phillips and Brian McGrath, have used a similar piece of equipment since April in the Advanced Orthopaedic & Spine Center at Buffalo General.

Dr. Sridhar Rachala say the Mako computer-assisted technology allows orthopedic surgeons to be more precise during knee replacement surgery. Such procedures appear to reduce pain and recovery time for recovering patients, he said. (Robert Kirkham/Buffalo News)

Both devices allow surgeons to take CT scans of a patient's damaged knee before surgery and map out how much bone from the tibia and femur need to be trimmed away to help fit two bone plates and a knee prosthetic snuggly into place. The parameters for the trims are transmitted by computer into the Mako robotic arm, which cuts precisely as it is guided into place by the surgeon.

It's worked well for Mogavero, 53. His physical therapist told him two weeks out from surgery that he was already was moving the way most patients do six weeks afterward.

"I'm able to pick my kids up and carry them where before it was just too painful," he said of daughter Quinn, 5, and son Jake, 3. "I'm back to golfing again, with no pain or swelling."

Rachala said he's heard similar things from many of his patients in similar shoes.

"Hopefully, these things are going to improve the results for everyone in the future," he said.

Q. How does this change knee replacement surgery in the region?

New robotic-assisted total knee replacement technology allows surgeons to be more patient-centered precise. The green portion will be cut away by the robotic saw blade during the procedure, Dr. Sridhar Rachala explains.
(Robert Kirkham/Buffalo News)

Previously, we had standard instrumentation. If I had to give you an analogy, if you're doing surgery and it's like shooting a dart. Somebody who's a rookie would have it all over the place. Somebody who's a seasoned surgeon hits more closely to the target. It's still not dead center. Now, think about a target that's moving, because everyone's knee is different. A knee is a complex joint. It's a common surface that's got multiple radiuses of curvature. It's got a flat surface that's not inherently stable. It's not contained. Then it has four ligaments, along with muscles and tendons, that stabilize it. When the knee moves, it doesn't just bend and straighten, it does this complex motion.

When we used to do a knee replacement, we were putting everyone on a single target with a standard mechanical alignment. We were trying to bring everyone onto a fixed target and trying to shoot for that target to get 'good enough' results. Every knee is different, so hopefully matching your knee to your anatomy would improve the satisfaction rate.

Q. What are the main advantages of this new type of surgery?

"There's no more jig, and no rod – just a couple of pins – so you can potentially do a less invasive surgery in a safe way," says Dr. Sridhar Rachala. He is pictured using a computer screen to help use the robotic-assisted arm during a recent knee replacement surgery in Buffalo General Medical Center. (Robert Kirkham/Buffalo News)

Number one is precision. You're precisely shooting a moving target which is specific for each patient, and you're able to achieve it very reliably with this machine because its readings are based off a CT scan. It precisely reproduces what the patient has. The second advantage is that because it's a robotic arm, with normal knee replacement, we have to open up the knee entirely. We put a rod inside the bone, put in a big jig and make the cut with a saw blade. We expose the tibia, put the jig in there and make the cut. With the robotic technology, all we need to do is open the joint and the saw blade aligns itself. There's no more jig, and no rod – just a couple of pins – so you can potentially do a less invasive surgery in a safe way. ... We don't have to dissect as much.

The third advantage is you can develop a personalized plan for every patient. You know what everyone's target is. … We input the bone landmarks so the sensor knows exactly where the bone is (and how it's shaped) in a three-dimensional space. Once we plan this, we can get the saw blade in and it aligns itself in the space in a precise way. It doesn't waver. It is safer because the saw blade is so precise it won't move out of alignment. If I tried to get out of the safe zone, it shuts off. It really is an amazing tool.

Q. So patient satisfaction is one of the things driving this?

Right now, it's good but not the greatest compared to the hip joint replacement. One in five patients have some type of pain and is not completely happy. Our goal is to achieve a difference by improving that patient satisfaction. One of the things that improves that is the ability to develop a personalized plan, preserve soft tissue and improve precision. It definitely has the potential to address all those things.

Q. How much does this Mako machine cost?

The machine itself is an investment of $1 million. It does all kinds of partial knees – inside, outside, underneath the knee cap. It also does hip replacements. An advantage of this machine is that it's so precise, once I put the template on, it will mill (the bone) to a micrometer. Once I put the trackers in, I press a button, the arm aligns itself into position and whatever saw blade I have put into the device cuts in an exact way. After that's done, we take the bone off and we go to the next cut. The arm and saw blade will then align itself into that plane. It's like the space technology where you're docking in a space station. You put in the numbers for the target, press a button and it aligns itself. Everything is in a circle. The trackers are communicating with the system, the system is communicating with the robot.

Q. What can readers do to try to prevent the need for knee replacement surgery?

Just for any disease process, there are quantifiable disease practices. There are non-modifiable factors, too. Maintaining an ideal body weight seems to be big in preventing arthritis. If somebody has crooked knees, obviously correcting that when they're younger helps. People who have injuries to the knees – ligament damage and meniscal tears – tend to be predisposed.

Q. Is this like Elon Musk talking about creating a human being that's part human and part machine?

We're not where Elon Musk is, at least not yet.

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Twitter: @BNrefresh, @ScottBScanlon

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