Knee replacement in India; technology - Cuvis joint replacement

By Dr Medha Gupta

Introduction

Knee replacement surgery is one of the most widely done orthopedic procedures worldwide.

Apart from aging, the urban lifestyle has triggered numerous muscular and skeletal problems, like widespread knee pain. When the condition is beyond oral medcation and physiotherapy, surgery is indicated. With the recent advances in technology, patient satisfaction and clinical outcomes are incomparable.

Prevalence of Knee Replacement in India

Statistics predict a high rate of increase in joint replacements in India between 2020 and 2026. Osteoarthritis of the knee in India is 15 times more prevalent than compared to the west. Studies say that the genetic composition and the regular activities of Indians are unfriendly to the knee. More than 15 crore Indians suffer from knee pain of some kind, of which about 4 crore Indians have to undergo a knee replacement surgery.

With the increase in the volume of patients seeking knee and hip replacements, efficient technology is required to perform the surgery faster, with minimal post-surgical risks.

Recent reports state that there have been plenty of metal insert and implant failure cases recorded worldwide and in India as well.

With all the requirements in mind, India has recognized the need for a JOINT REGISTRY in the country and has become a member of the WORLD OF HIP AND KNEE REGISTRIES in recent times.

There has been a paradigm shift in the technology used for Knee replacement surgeries in India. In the present era of Artificial intelligence (AI), and Computer sciences, biomedical engineering has reached its zenith.

The projected scores for successful knee replacements in India by the year 2026 are commendable.

Cuvis joint replacement is one of the latest developments in this field.

Causes of Knee osteoarthritis:

• Excessive wear and tear of the knee joint due to strenuous activities

• Sports

• Injury

• Obesity

• Misaligned knee joint

• Genetics / hereditary

• Vitamin D deficiency

• Certain biochemical changes in the body fluids

Classical symptoms of Osteoarthritis:

• Severe pain in the knee

• Reduced joint mobility

• Difficulty in walking without a support

• Condition of the joint worsening even after conservative treatment

How does the orthopedic surgeon diagnose Osteoarthritis?

• Check the complete range of movements of the knee

• Advise X-rays

What do you expect to see in an X-ray of an Osteoarthritic knee?

• The knee joint space narrowing

• Osteophyte formation - A bony spur ( growth ) at the end of the bone

• Bone thickening ( Subchondral sclerosis )

• Small cysts

The first line of Treatment for Knee Osteoarthritis:

• Medication: Over The Counter (OTC) anti-inflammatory pain medicines.

• Physiotherapy

• Stabilizing the joint with a brace

• Activity Modification

• Dietary supplements

• Weight loss

• Steroid injections in the joint

Indications for a Knee replacement surgery :

When the classical signs and symptoms of Osteoarthritis fail to get by relieved by conservative means.

When is a Knee replacement surgery not advised?

• Severe comorbidities

• Any infection present

• Nerve related issues of the joint

• The skin over the knee is affected

• Poor blood supply to the joint

• Psychological problems

• Poor patient motivation

What is a Knee replacement surgery?

Knee replacement surgery also called KNEE ARTHROPLASTY ( KA ) can be of 2 types:

1. Total KNEE ARTHROPLASTY (TKA)

2. Partial KNEE ARTHROPLASTY ( PKA)

Total KNEE ARTHROPLASTY (TKA):

All surfaces of the knee joint are replaced for smoother functioning.

Involves the following steps:

1. The procedure involves hospital admission and a full-body health work-up

2. Pre-procedure General anesthesia administered

3. The knee joint is exposed and examined

4. The damaged cartilages are removed from 3 areas - the hip bone (femur) end, the shin bone (tibia) end and any other underlying bone.

5. Resurface the under part of the knee cap

6. The bone surfaces are prepared to receive the artificial implants.

7. The implants are either Press fitted or cemented with medical-grade cement

8. A plastic button is placed under the knee cap

9. Medical grade plastic spacers are placed over the implant inserts for the smoother gliding of the joint

10. The joint is correctly aligned

11. The overlying skin is stitched back

Post Surgical care :

• Initially, the leg feels stiff and painful

• Necessary pain medications are given

• Blood thinners are prescribed to prevent clotting

• Physiotherapy is started early to allow natural blood flow and healing

• A machine is advised that is used to brace the knee and allow passive movements.

Partial KNEE ARTHROPLASTY ( PKA)

Only a part of the knee is replaced when any of the 3 compartments of the knee is affected by osteoarthritis.

The metal insert and plastic components are placed on the prepared surfaces of the hip bone, the shin bone or the knee cap as indicated.

Advantages of a PKA:

• Faster recovery

• Faster rehabilitation

• Less post-surgical trauma

• Less invasive

Disadvantages of PKA:

• Incomplete elimination of pain

• Residual damaged cartilage

• The probability of a TKA in the future

Complications of a Knee Replacement Surgery:

• Knee stiffness and reduced mobility

• Nerve damage around the knee

• Bleeding at the site

• Residual blood clots

• Breathing problems post-anesthesia

Techniques of a knee replacement surgery:

1. Traditional Knee Replacement surgery:

Involves the incision of the quadriceps tendon and the complete turnover of the kneecap to access the arthritic joint.

The recovery time is longer in this technique.

1. Minimally invasive Knee Replacement surgery:

Minimally invasive surgery (MIS) involves a shorter incision cut and the kneecap that is pushed to the side and not turned over. The implants placed are similar to traditional surgery.

Types of MIS:

1. Quadriceps sparing approach - The kneecap is pushed aside to access the joint without incising the quadriceps tendon

1. Lateral approach - The arthritic joint is accessed laterally without touching the quadriceps.

Advantages of the Minimally invasive Knee Replacement surgery:

• Faster recovery time

• Quicker healing

• No complications of bleeding and blood clots

• Mobility of the joint is enhanced as the tendon and muscles are not incised

3. Computer-assisted surgery ( CAS )

The scans of the knee joint are registered in a computer that generates a 3-D model of the knee. The software aids the surgeons in precise and less invasive surgery.

Robot-assisted Total Knee Replacement:

Robotic surgery is not aimed at a Robot replacing a surgeon, it merely is an AI-based programmed software that assists the surgeon in the surgery.

The first Robotic TKA was performed as early as 1988 in the United Kingdom.

When should you not opt for robotic surgery:

When the patient is susceptible to infections, then a conventional approach is preferred. The surgical time is prolonged in Robotic surgery and the site remains open for a longer period.

Advantages of a Robot-assisted Total Knee Replacement:

• Precision and accuracy in implant positioning

• The muscle and ligament balance is better achieved

• The alignment of the bones in the joint is accurate.

• Postoperative recovery is smooth

Techniques in Robot-assisted Total Knee Replacement:

• Fully-active - The bot is used for actively cutting the bone and placing the implants

• Semi-active - The bot is programmed for visual, audio, and tactile feedback to guide the orthopedic surgeon in the amount of force applied, the direction of movements, and the placement of the metal inserts.

Types of available Robot-assisted Systems in Total Knee Replacement:

• A semi-active robotic arm - Assists the surgeon through a haptic interface. Creates a 3-D model using the CT images to accurately measure the extent of bone resection, implant position, and size.

• A semi-active robotic burr - It is to be manually operated by the surgeon and guides the path and motion of the bur to cut the bone and place the implant.

It does not require a CT scan.

• An active system - The robotic elements do both the bone resection and the implant positioning.

A CT scan of the knee is required to start the treatment plan.

• A motor-powered robotic device - It is not pre-programmed, but assists in all the steps of the surgery.

Commercial names for a few Robot-assisted Systems in Total Knee Replacement:

• ROBODOC (CurexoTechnology, Fremont, CA)

• CASPAR (URS Ortho GMBH & Co, KG, Rastatt, Germany)

• Mako (Stryker, Mahwah, NJ)