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The Physician's Role During MAKOplasty: Q&A With Dr. Frank Noyes of Cincinnati SportsMedicine & Orthopaedic Center

Written by  Laura Dyrda | Monday, 13 September 2010 16:12
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Robotic assistance in surgical procedures has been prevalent for years in several medical specialties; however,robotic systems are only just beginning to evolve in orthopedics. Researchers across the country are involved in trials to develop robotic technology that will improve patient outcomes for orthopedic surgery. The MAKOplasty robotic system is currently available to assist physicians in partial knee replacement surgery, though many physicians are weary of making the change. Frank Noyes, MD, chairman and CEO of Cincinnati SportsMedicine & Orthopaedic Center, discusses the physician's role in utilizing the MAKOplasty system.


Q: What is the process for a physician utilizing the MAKOplasty robotic system for partial knee replacement surgery?

Dr. Frank Noyes: The MAKOplasty robotic system for partial knee replacement surgery is different than the robotic system used in cardiac procedures, general surgery and prostate procedures. In those systems, the surgeon sits in a module and moves his hands to guide the robot arm equipped with instruments. The surgeon performs the surgery viewing a monitor.The robotic system used in knee joint surgery is entirely different. The robotic computer and arm is preprogrammed using the CT scan of the patient's knee. The CT allows the three dimensional unique anatomy of the patient's knee to be loaded into the computer system and then the surgeon registers different anatomical marks from the knee at the time of surgery into the computer.

Then, the surgeon uses the robot computer to position the knee replacement components exactly on the knee joint.  The key to using this sophisticated computerized robotic equipment is that the surgeon has the opportunity to select the exact placement of the implant prior to surgery and also at the time of surgery from a three-dimensional standpoint thereby increasing the accuracy of placement in the knee joint.

Q: If the robot is preprogrammed to perform the surgery, what is the physician's role during the surgery?


FN: The role of the surgeon is to move the robotic arm forward and backward, up and down and produce the bone cuts into which the implant is placed. The robot is an intelligent preprogramned instrument. The surgeon also can tell with experience that the bone cuts are correct and adjust any bone cut as needed. The surgeon has the ability to say 'I think we are cutting too much bone from this area' and can reprogram the computer to cut less or change the alignment of the implant.

When I'm asked whether I or the robot is performing the surgery, I explain that I am in charge. One of the important things the surgeon has to do is select the width of the implant to balance the ligaments because you have to provide stability to the knee joint. The surgeon performs the virtual surgery on the computer with the implants. The robot is the tool which carries  out the surgery totally under the surgeons hands.

Q: What types of surgeons benefit most from this technology?

FN: There are many surgeons who have performed partial knee replacements over the years and have developed excellent skills and patient outcomes. These surgeons may state with justification that they do not need a robotic computerized system to accurately perform partial knee replacements. Remember when the surgeon does a partial replacement there are two components, namely on the femur (thigh bone) and one on the tibia (leg bone) that must be aligned with great precision allowing mobility, stability and without tilting or displacements that would cause uneven wear and eventual failure. The robotic arm really comes into play for those surgeons who may not be performing a high volume of partial knee replacements. It really helps the surgeons in learning the techniques for partial knee replacement.

The more surgery you do the more expertise you develop. I think the robotic arm is really going to have a role in hospitals and orthopedic practices where physicians perform fewer partial knee replacements. Despite a lower volume of patients, the physicians still want to offer their patients a precise procedure. Also, even with experienced knee surgeons, there is always the chance of a misalignment of the tibial and femoral implants at surgery that is really not possible with the robotic system. The Mako system gives an added assurance in achieving an excellent placement of the knee prosthesis.

Q: How easy or challenging was it to train on the MAKOplasty robotic arm?

FN: I don't think it was very difficult to learn. The system is so elegantly designed that you have the knee an anatomy right in front of you in three different views. Surgeons are familiar with looking at these views because the views are similar to what physicians see when examining CT and MRI. It is easy for the physician to switch between the different three-dimensional views in the robotic computer when they use the prosthesis. It's a very user-friendly system.

The one problem that can occur at surgery is when you digitize the patient's actual limb and knee anatomy into the computer buy using a probe to record certain patient anatomical points. This must be a careful accurate process otherwise the computer may provide incorrect cutting instructions to the robotic arm..

Q: Is it cost-effective for physicians to utilize robotics in orthopedic surgery?


FN:
The initial companies that went into using robotics for  knee replacement surgeries found it was not cost-effective and five years of research all dried up. In the future, new models might be cheaper. For physicians, it is important for the procedure to be cost-effective, but it is also important to perform a procedure that is reliable, highly accurate and in the most reproducible manner for the highest achieved patient outcome and longevity of the knee implant. Even with my experience over 30 years in doing knee surgery I found the Makoplasty to achieve in my patients and even more reproducible outcome in terms of implant alignement and placement. Only long term studies with many surgeons can provide the scientific data to answer cost effective questions.

Disclosure: Dr Frank Noyes has no conflict of interest and does not own any stock or receive compensation of any kind from Makoplasty. Dr Noyes performs the Makoplasty knee surgery at Jewish-Mercy Hospital Medical Center which has owned the system for two years.

Learn more about Cincinnati SportsMedicine & Orthopaedic Center.


Read other coverage on MAKOplasty:

- First Michigan MAKOplasty Performed at Blodgett Hospital


- MAKO Surgical Corp. Releases First Quarter Earnings, Revenues Reach $7.2M


- MAKO to Unveil Next-Generation Robotic Arm System



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