Robotics and Modern Approaches to Hip and Knee Replacement

This is a recording of “Robotics and Modern Approaches to Hip and Knee Replacement,” a Zoom presentation held on May 17, 2023.

Below is an excerpt of a presentation given by Dr. Matthew Sloan, who received his MD from the University of Massachusetts Medical School and completed his internship in general surgery and residency in orthopaedic surgery at the University of Pennsylvania. He worked in joint replacement at the Brigham & Women’s Hospital, where he worked with national leaders in robotic-assisted joint replacement, custom total joint replacement, and more. After leaving Brigham & Women’s, Dr. Sloan joined Orthopedic Affiliates in Concord Massachusetts. He performs his surgeries at Emerson Hospital. He has published widely and presented at many national conferences on many aspects of modern joint replacement, patient optimization, and improving outcomes.

I just want to give folks an overview of what the modern total joint replacement treatment options are, who’s a candidate for these things and talk a little bit about robotics. This is a talk that I adapted a few months back that I gave to the primary care physicians and some of the internal medicine folks at Emerson where I do my joint replacement surgeries. We’ve been switching over exclusively to robotic assisted surgery since June of 2022 so at the time I gave this talk, just about a year ago, we had just been working to get robotic assistance at Emerson. Now we have that so let’s talk about what that means for joint replacement in our community. Just a disclosure – I don’t have any financial conflicts with any of the material that I’m going to present. I do use this robotic system called Mako Smart Robotics. It’s owned by a company called Striker but I’m not a paid consultant for them or anything.

So, this is a guide of X-rays and it helps us figure out who is a candidate for joint replacement. The talk that I have with any patient that I see in the office that comes in with hip or knee pain is, “are you a candidate for joint replacement. If you’re not a candidate for joint replacement, what kinds of treatments could you have that don’t require a surgical intervention?” But this guide to reading X-rays just shows you this is a knee joint and the femur or the thigh bone is up top and the tibia or the shin bone is down below. What we can see in the middle is the empty space and that’s where the cartilage lives. So, when we look at an “A” on the on the left side of the screen there’s a lot of empty space between the thigh bone and the shin bone. This person likely has a lot of cartilage. As you move to the right and you get into the “C” and “D” range, that empty space is disappearing and you’re starting to see some bone spurs indicated by the arrows and then eventually you have bone on bone arthritis. We call it bone on bone arthritis because the two bones, the thigh bone and the shin bone that makeup the knee joint, are now touching and these patients are ones who are candidates for joint replacement. Up until then, we treat knee pain or hip pain with non-surgical treatments but when you get into this stage you become a candidate for knee or hip replacement.

Just because you meet the criteria for joint replacement doesn’t mean you need to have a joint replacement. It’s elective surgery meaning it’s not like heart surgery. You don’t have to have surgery tomorrow but if your symptoms are bad enough and if you meet criteria, it might be worth it for you to consider joint replacement surgery as a treatment option to improve your pain quality of life, loss of function or deformity. You have to meet both these criteria appropriateness based on X-rays and then the clinical criteria that your symptoms are bad enough that the risks of surgery may be worth it.

The other important thing is, do you meet criteria, are your symptoms bad enough and are you healthy enough for surgery. So, these are what we call modifiable risk factors. Patients who are active smokers are not good candidates for elective surgery because of the risks of infection. Wound healing patients with uncontrolled diabetes have higher risk for wound healing and infection and patients who have had recent cortisone or steroid injections have to wait at least three months until we do a joint replacement for patients who have a BMI over 40 and again because of wound concerns. The last one I highlight has to do with folks who are using narcotics for pain control preoperatively. We try to wean patients off narcotics before surgery so that the narcotics that they might need to use after surgery are more effective and they haven’t built up a tolerance.

So those are the things that we really look at because there are known risk factors for complications after surgery. Other folks just need to see their primary care doctor or cardiologists. If they see a cardiologist regularly in order to be evaluated to make sure there’s nothing that needs to be checked or improved upon before surgery.

To continue learning about hip and knee replacements, watch the full presentation.