Computer navigation is available for orthopedic physicians performing knee surgery. The equipment is designed aid the physicians with incision placement and depth, implant placement and bone resections based on the patient's individual anatomy.
"The main advantage of using computer navigation in robotic surgery is you can be more accurate," says Fabio Orozco, MD, a physician with the Rothman Institute in Philadelphia.
Several products, such as the PiGalileo system and MAKOplasty, have been developed to assist physicians with knee surgery. These products are in early generations of development and some physicians are skeptical about the benefits.
"There's about five percent penetration of this technology among the orthopedic surgeons in this country," says Mark Raklewicz, MD, a physician with Orthopaedic Consultants of Wyoming Valley in Kingston, Penn. "I'm in the vast minority of guys that like it and I think we're ahead."
Even physicians who have performed several surgeries in the past can benefit from this technology because the computerized system gives real time feedback to the physician during the procedure.
"The computerized system helps highly experienced surgeons understand why they get good outcomes," says Gary Botimer, MD, of chairman of the department of orthopedic surgery at Loma Linda (Calif.) University Medical Center. "This technology gives me feedback that improved the quality of my surgery."
How systems work
The PiGalileo technology attaches to the knee with a clamp and registers the contour of the knee, measuring the size and alignment. The computer tells the robot where the blocks should be placed for the incision and then the physician makes the incision.
For procedures using the MAKOplasty system, physicians preprogram the equipment with a CT scan of the patient's knee. The computer transforms the scan into a three-dimensional view of the patient's anatomy where the physician can register the individual anatomical marks for each patient. Then, the physician can preplan the surgery, judging the amount of bone resection.
"The computer makes surge the physician does exactly the right amount of resection," says Dr. Orozco.
The physician also uses the robot computer to position the knee replacement components exactly on the knee joint.
"The computer allows you to customize to the patients depending on the circumstance of the knee," says Craig Levitz, MD, director of sports medicine and chairman of the department of orthopedics at South Nassau Communities Hospital in Oceanside, N.Y. "We have no reason not to make a knee replacement perfect every time."
Additionally, Dr. Botimer says in order to maximize quality outcomes surgeons should be familiar with how the computer is deriving the information for the surgery, though physicians can perform the surgery without understand how the computer derived the information.
"When you understand what the graphs are telling you and you have a good computer system, you can predict better balance and alignment," says Dr. Botimer. "If the physician understands the navigation at this point, they can get 70 to 80 percent of the information they need in order to make the surgery perfect."
By understanding how the information was derived, physicians can refine the ligament balancing for best results in post-operative knee stability.
Correcting judgments
Though the physician preplans the surgery on the computer, the computer allows the surgeon to alter directions during procedures.
If the physician miscalculates and needs to take more bone during the bone resection, he or she can reprogram the computer to make additional resections. If too much bone is taken, the computer can balance that error by taking more bone from the other knee dimensions and then placing additional polyethylene on the site.
Dr. Levitz says making these corrections is quicker with the computer than without.
The PiGalileo system can also compensate for shallow cuts. The program is able to make ½ millimeter incision corrections.
"If you think the cut is not deep enough, you can go at ½ millimeter cuts until it is right," says Dr. Raklewicz.
Cost-effectiveness: surgery time
Using computer-assisted technology takes at least 10-20 minutes longer than performing the surgery without the computer assistance. This means the physician is spending extra time in the operating room without receiving extra reimbursement.
"While you are going through a learning curve, the surgery takes an especially long time," says Dr. Orozco. "However, as you perform more surgeries, the surgery time decreases."
For the moment, increased surgery time is not cost-effective for the physicians, even though using this technology creates better outcomes for the patients.
"I think outcomes are the most important things and I will sacrifice revenue to ensure my patient's outcome," says Dr. Levitz. "Medicine is not just a business. It is a trust and obligation. Ultimately you want the best things for your patients and I think robotics and computers can give physicians the best outcomes."
In the future, using computer-assistance and robotic technology could prove cost-effective because physicians can reuse the equipment. Additionally, the preciseness of the surgery means fewer patients will need revision surgery. Revision surgery, says Dr. Levitz, is one of the highest contributors to the cost for healthcare in the country.
Equipment costs
Some types of equipment can cost the physician or healthcare provider thousands of dollars, which means physicians using this equipment often do an outstanding number of knee replacements every year.
"At a center where you don't do hundreds of joint replacements, the cost wouldn't make sense," says Dr. Levitz.
Future technology
While computer-assisted and robotic surgeries have created a much more precise surgery, the next step in this technology will be technology that analyzes and balances the ligament before the physician commits to a cut.
"What people don't realize is how much potential is within the computer system," says Dr. Botimer. "Up to now, we've hardly tapped the potential."
Read more about robotics in orthopedic surgery:
- The Physician's Role During MAKOplasty: Q&A With Dr. Frank Noyes of Cincinnati SportsMedicine & Orthopaedic Center
- Computer-Assisted Knee Surgery: Using the PiGalileo System for Incision Accuracy
- Beyond Traditional Knee Surgery: Options for Knee Surgery With Better Outcomes
"The main advantage of using computer navigation in robotic surgery is you can be more accurate," says Fabio Orozco, MD, a physician with the Rothman Institute in Philadelphia.
Several products, such as the PiGalileo system and MAKOplasty, have been developed to assist physicians with knee surgery. These products are in early generations of development and some physicians are skeptical about the benefits.
"There's about five percent penetration of this technology among the orthopedic surgeons in this country," says Mark Raklewicz, MD, a physician with Orthopaedic Consultants of Wyoming Valley in Kingston, Penn. "I'm in the vast minority of guys that like it and I think we're ahead."
Even physicians who have performed several surgeries in the past can benefit from this technology because the computerized system gives real time feedback to the physician during the procedure.
"The computerized system helps highly experienced surgeons understand why they get good outcomes," says Gary Botimer, MD, of chairman of the department of orthopedic surgery at Loma Linda (Calif.) University Medical Center. "This technology gives me feedback that improved the quality of my surgery."
How systems work
The PiGalileo technology attaches to the knee with a clamp and registers the contour of the knee, measuring the size and alignment. The computer tells the robot where the blocks should be placed for the incision and then the physician makes the incision.
For procedures using the MAKOplasty system, physicians preprogram the equipment with a CT scan of the patient's knee. The computer transforms the scan into a three-dimensional view of the patient's anatomy where the physician can register the individual anatomical marks for each patient. Then, the physician can preplan the surgery, judging the amount of bone resection.
"The computer makes surge the physician does exactly the right amount of resection," says Dr. Orozco.
The physician also uses the robot computer to position the knee replacement components exactly on the knee joint.
"The computer allows you to customize to the patients depending on the circumstance of the knee," says Craig Levitz, MD, director of sports medicine and chairman of the department of orthopedics at South Nassau Communities Hospital in Oceanside, N.Y. "We have no reason not to make a knee replacement perfect every time."
Additionally, Dr. Botimer says in order to maximize quality outcomes surgeons should be familiar with how the computer is deriving the information for the surgery, though physicians can perform the surgery without understand how the computer derived the information.
"When you understand what the graphs are telling you and you have a good computer system, you can predict better balance and alignment," says Dr. Botimer. "If the physician understands the navigation at this point, they can get 70 to 80 percent of the information they need in order to make the surgery perfect."
By understanding how the information was derived, physicians can refine the ligament balancing for best results in post-operative knee stability.
Correcting judgments
Though the physician preplans the surgery on the computer, the computer allows the surgeon to alter directions during procedures.
If the physician miscalculates and needs to take more bone during the bone resection, he or she can reprogram the computer to make additional resections. If too much bone is taken, the computer can balance that error by taking more bone from the other knee dimensions and then placing additional polyethylene on the site.
Dr. Levitz says making these corrections is quicker with the computer than without.
The PiGalileo system can also compensate for shallow cuts. The program is able to make ½ millimeter incision corrections.
"If you think the cut is not deep enough, you can go at ½ millimeter cuts until it is right," says Dr. Raklewicz.
Cost-effectiveness: surgery time
Using computer-assisted technology takes at least 10-20 minutes longer than performing the surgery without the computer assistance. This means the physician is spending extra time in the operating room without receiving extra reimbursement.
"While you are going through a learning curve, the surgery takes an especially long time," says Dr. Orozco. "However, as you perform more surgeries, the surgery time decreases."
For the moment, increased surgery time is not cost-effective for the physicians, even though using this technology creates better outcomes for the patients.
"I think outcomes are the most important things and I will sacrifice revenue to ensure my patient's outcome," says Dr. Levitz. "Medicine is not just a business. It is a trust and obligation. Ultimately you want the best things for your patients and I think robotics and computers can give physicians the best outcomes."
In the future, using computer-assistance and robotic technology could prove cost-effective because physicians can reuse the equipment. Additionally, the preciseness of the surgery means fewer patients will need revision surgery. Revision surgery, says Dr. Levitz, is one of the highest contributors to the cost for healthcare in the country.
Equipment costs
Some types of equipment can cost the physician or healthcare provider thousands of dollars, which means physicians using this equipment often do an outstanding number of knee replacements every year.
"At a center where you don't do hundreds of joint replacements, the cost wouldn't make sense," says Dr. Levitz.
Future technology
While computer-assisted and robotic surgeries have created a much more precise surgery, the next step in this technology will be technology that analyzes and balances the ligament before the physician commits to a cut.
"What people don't realize is how much potential is within the computer system," says Dr. Botimer. "Up to now, we've hardly tapped the potential."
Read more about robotics in orthopedic surgery:
- The Physician's Role During MAKOplasty: Q&A With Dr. Frank Noyes of Cincinnati SportsMedicine & Orthopaedic Center
- Computer-Assisted Knee Surgery: Using the PiGalileo System for Incision Accuracy
- Beyond Traditional Knee Surgery: Options for Knee Surgery With Better Outcomes