September 01, 2010

Beyond Traditional Surgery: Options for Knee Surgery With Better Outcomes

As the methods for knee surgery evolve, physicians are increasingly turning to innovative technology in robotics and computer-assisted surgery as well as biologic options for treating patients. While these methods may not be entirely cost-effective for the physician, they can provide better and more predictable outcomes as well as increased patient satisfaction.

Robotic technology. In the past, physicians have used their professional judgment on where to place the cutting blocks for knee surgery. Now, robotic controlled technology is able to ensure the blocks are placed accurately for each individual patient. "We have no reason not to make the knee replacement perfect every time," says Craig Levitz, MD, director of sports medicine and chairmen of the department of orthopedics and orthopedic surgery at South Nassau Communities Hospital in Oceanside, N.Y. Robotic technology is preprogrammed with a CT scan of the patient's knee which allows the physician a three-dimensional image of the knee. The physician registers the patient's anatomic marks in the computer and then moves the robotic system up and down during the surgery.

"The downside of this technology is that the computer takes longer to perform the surgery," says Dr. Levitz. "It takes significantly longer and you're paid for the same amount of time as if you were doing the procedure without robotics."

When using robotic technology, the incision can be made much smaller than in non-robotic surgeries. The robotic arm will not allow the physician to cut past the preprogrammed perimeters. However, the physician has the ability to reprogram the computer in order to correct errors, such as cutting too much bone from one area, making the corrections easier and quicker than without robotic technology.

Biologic knee replacement. Performing biologic knee replacement is a multi-step procedure. Physicians first remove the bone and cartilage matter from the patient's knee, which is then ground together in order to create a paste. In the second step, the physician spreads the paste over damaged cartilage in order to stimulate growth. The patient's damaged meniscus is replaced by a cadaver meniscus. Biologic techniques are appropriate for middle-age and active patients with significant degeneration. "There are many people who are several years out from biologic knee replacement surgery and essentially they have been able to return to all activities after biologic treatment," says James Gladstone, MD, co-chief of sports medicine and assistant professor of orthopedic surgery at Mount Sinai Medical Center in New York City. However, the rehabilitation for biologic knee replacement patients takes longer because the patients cannot begin full weight bearing activities immediately after surgery.

The biologic knee replacement procedure is relatively new and long-term affects have not been clinically determined. Additionally, not all payors will cover the surgery. "You are making the decision to do this massive surgery that will probably work," says Dr. Gladstone. "The patient is not guaranteed he or she won't need a knee replacement."

Platelet Rich Plasma. The PRP injection stimulates cartilage growth in a knee injury not able to heal on its own. Physicians must extract the patient's blood and separate the plasma in order to create the injection. Researchers and physicians are still debating as to whether this is an effective treatment for patients with knee damage. Many professional athletes use PRP treatment in order to return to work quickly.

Double-bundle surgery. Physicians performing the double-bundle ACL reconstruction procedure use two small grafts instead of the one large graft (used in the single-bundle procedure) to reconstruct the ligament. As a result, the double-bundle requires four bone tunnels and one additional incision to accommodate the second graft. Thomas Vangsness, MD, chief of sports medicine at L.A. County/USC Orthopaedic Surgery in Los Angeles, is one of the few physicians trained to perform this procedure. He recommends patients receive a double-bundle because the positioning of the arthroscopic tunnels is less vertical and the two grafts allow for better rotation after the surgery.

The double-bundle ACL reconstruction is more expensive than the single-bundle procedure because it takes longer and is more technically difficult, says Dr. Vangsness. The physician must be able to create all four holes and implant the grafts accurately. Revisions in a knee with the double-bundle surgery are difficult because of the extra tunnels. Dr. Vangsness recommends physicians who perform a high volume of ACL reconstructions pursue this procedure.

Youth ACL reconstruction. In the past, physicians would not recommend knee surgery to young patients because implants were too large and damage to the growth plates would stunt the patient's growth. However, an unstable knee causes more problems in young patients. New technology and smaller implants help physicians stabilize a young patient's knee. "It's not like fixing a little adult," says Peter Millett, MD, M.Sc., partner at Steadman Clinic in Vail, Colo. Instead of placing bone across the tunnel as physicians do in procedures with adult patients, the physician should leave only soft tissue across the growth plate at an appropriate angle to avoid growth arrest in the patient. Since the young patient is still growing, he or she will need an individually tailored implant that will allow additional growth to continue.

- http://beckersorthopedicandspine.com/sports-medicine/1910-beyond-traditional-surgery-options-for-knee-surgery-with-better-outcomes

- http://www.vangsnessmd.com/