Rosa: Embracing the Future of Medicine with the Robotic Surgical Assistant

Rosa: Embracing the Future of Medicine with the Robotic Surgical Assistant

Knee joint replacement surgery serves as a vital surgical intervention for those grappling with degenerative knee joints, aiming to restore their mobility and overall quality of life. 

Imagine a scenario in which medical technology takes a monumental leap forward, introducing a robotic knee replacement system designed to enhance treatment effectiveness. This innovation prompts numerous inquiries regarding its safety and reliability compared to human surgeons. People question whether the procedure solely depends on the robotic system and how it outperforms the traditional approach.

We discussed with Dr Siripong Ratanachai, an orthopedic surgeon with expertise in Arthroplasty; Dr Siripong has conducted numerous robotic-assisted surgeries, providing him with valuable insights into the strengths and limitations of the system. These insights highlight the capacity of skilled surgeons to complement the technology and achieve optimal treatment outcomes, thus fostering hope for patients.

Knee replacement surgery: A Trusted Treatment Choice

Knee replacement surgery is a procedure that focuses on addressing damaged surfaces within the knee joint, particularly those at the lower end of the femur and the upper end of the tibia, where cartilage typically provides cushioning. This intervention targets the impact of aging and the natural erosion of cartilage, which can lead to the exposed ends of bones rubbing against each other, resulting in a characteristic crepitation sound from the knees.

The early stage of knee osteoarthritis is painless since cartilage lacks nerve endings. However, as the condition progresses to an advanced stage, the exposed bone, which contains blood vessels and nerves, becomes a source of knee pain, inflammation, and swelling.

Risk factors of knee degeneration include:

1. Unmodifiable factors:
   
   • Gender: Women are at a higher risk of developing knee osteoarthritis compared to men.
   • Genetics: Some individuals inherit genes predisposing them to weaker joint cartilage, increasing their susceptibility to osteoarthritis.
   • Abnormal bone parenchymal structure.
2. Modifiable factors:
   • Overweight: Excess body weight places additional pressure on knee joints, exacerbating the risk of joint degeneration.
   • Inadequate treatment following knee joint injuries.
   • Inappropriate use of the knees with recurrent and excessive joint stress.
   • Knee joint infections.
   • Unmanaged arthritis conditions, such as rheumatoid arthritis, gout, and other forms of arthritis, can contribute to knee degeneration if not treated optimally. 

“Despite being cautious with your knee health, natural wear and tear can still take its toll. When the cartilage becomes significantly worn, the recommended treatment often involves a surgical procedure to replace the damaged portion of the knee with a prosthesis.”

The success of knee joint replacement surgery depends on the following four critical factors

• Patients' factors: It is essential that the stage of knee osteoarthritis is appropriate for replacement surgery, and patients must actively cooperate with their healthcare providers by adhering to post-operative care instructions.
• Materials for Artificial Knee Joints: The materials chosen for artificial knee joints must meet the highest quality standards and be well-suited to individual patient needs.
• Expert Surgeons: Experienced surgeons play a pivotal role in determining the most suitable treatment approach, performing the surgical procedure, and selecting the optimal location for the prosthesis implantation site.
• Well-Prepared Hospitals: Hospitals should exhibit reliability, maintain a low infection rate, possess state-of-the-art tools and technologies, and have a dedicated team of specialists available to provide treatment in the event of complications.

“Complications can arise during any surgical procedure, irrespective of a patient's preexisting conditions or a specific surgical approach employed. While such occurrences are relatively rare, undergoing surgery at well-prepared hospitals staffed by multidisciplinary teams of specialists and equipped with state-of-the-art tools can ensure a smoother surgical journey, ready to address any contingencies.”

Nonetheless, knee replacement surgery may not always yield the most satisfactory outcome. Suboptimal positioning or orientation of the artificial knee joint may necessitate additional corrective surgery. Furthermore, factors such as stretched ligaments, lack of exercise, and the natural aging process can lead to the joint becoming excessively loose. Additionally, conditions like osteoporosis can cause a reduction in bone length, potentially affecting the previously well-operated joint. Therefore, in addition to surgical expertise, incorporating technology that enhances surgical precision can help minimize the risks of errors, unexpected outcomes, and the need for further surgical interventions.

A robotic surgical assistant (ROSA) for knee replacement surgery is most effective when paired with an experienced surgeon

“Physicians have consistently sought to leverage technological advancements to enhance the efficacy of surgical procedures, increase the likelihood of success, and minimize errors. A prime example is the utilization of a robotic surgical assistant. However, seasoned surgeons must be the individuals wielding this technology, as they can harness its full potential while simultaneously addressing its limitations.”

Robotic-assisted knee replacement surgery involves using a mechanical robotic arm to aid in the surgical procedure to precisely locate the plane for bone resection or resurfacing. This technology aims to enhance precision and reduce the likelihood of errors, making the surgeon's role as error-free as possible. There are two main types of robotic arms: one equipped with a guidance system and another with a saw at the end of the arm.

“Typically, the surgical error rate is around 3 percent; however, robotic surgical assistants can reduce this rate to 1 percent or even less. While these percentages may appear low in isolation, it's essential to consider the sheer volume of knee replacement surgeries performed annually, translating to a substantial number of patients. Every patient and surgeon aspire to achieve a successful operation, with no one desiring to be responsible for a mistake.”

Traditional knee replacement surgery involves making a lengthy incision to gain visual access to the leg bones' anatomy. Alternatively, the surgeon may insert an intramedullary metal rod into the leg bone shaft to aid in angle measurement, potentially resulting in considerable blood loss. In contrast, robotic-assisted surgery begins with a registration step in which the surgeon places small devices at predetermined locations on the bones. Subsequently, a tracker marks these devices, and computer software generates a 3D representation of the patient's knee and leg bone structure. This virtual model serves as a reference for the spatial orientation of the surgical plane.

“This technology offers the advantages of reduced surgical incision size, minimized tissue trauma, and enhanced effectiveness. The surgeon inputs all the necessary data, and the machine then calculates the optimal plane for bone cutting. The subsequent steps depend on the discretion of the surgeons. They can follow the robotic system's calculations or make modifications based on their expertise and experience to achieve a more suitable incision plane.”

As stated by Dr Siripong, despite the increased precision enabled by robotic surgical assistants, there is no one-size-fits-all formula for success in actual surgical procedures. Given the unique anatomical characteristics of each patient's knee, adaptability and innovation play a pivotal role in surgery. Consequently, the surgeon who employs a robotic surgical assistant remains paramount in the successful outcome of knee joint replacement surgery.

“Many have expressed the view that robotic surgical assistants simplify the tasks of surgeons, but I hold a different perspective because the robotic system generates the image of a bone solely based on the data it collects. Its vision is limited to bones without factoring in critical elements such as muscles, ligaments, nerves, and blood vessels. The exclusion of these soft tissues from the calculation can, sometimes, lead to recommended bone cutting in areas that are practically impossible due to the presence of vital soft tissues. Surgeons must identify an appropriate angle for bone cutting that avoids potential harm to these essential anatomical structures.”

Dr Siripong prefers a robotic arm with a guidance system to the one with a built-in saw, citing its greater convenience and flexibility for making orientation adjustments.

He explains, “The robotic guidance system operates by basing calculation on collected data. Like a GPS navigation system, it can occasionally lead you off course; an experienced surgeon is vital in correcting deviations and getting on the right track before magnifying errors.”

He highlights the advantage of using ROSA, stating, “ROSA offers a heightened level of precision. When a surgeon specifies a 90-degree angle, ROSA will deliver without deviations like 92 or 89 degrees. This precision is a significant advantage for the surgeon.”

Dr Siripong guides on when it is suitable for surgeons to consider utilizing a robotic surgical assistant:

• In cases involving severe bone deformity.
• When metal plate fixation is present, it may interfere with intramedullary rod insertion into the leg bones.

In these situations, a robotic surgical assistant can significantly benefit patients by enhancing precision and eliminating the requirement for a large incision to remove the metal fixation plate.

Surgeon + Robot, A Dynamic Team for Optimal Treatment Outcomes

“The secret to a successful surgery lies in the seamless collaboration of technology, physicians, and skilled professional staff.”

When questioned about the rates of knee revision surgery in patients who have undergone ROSA knee replacement surgery, Dr Siripong stated that these rates have gradually declined over time. This reduction can be attributable to the extended lifespan of artificial knee joints, which is achieved by selecting the most appropriate prosthetic components and conducting precise bone resection. This approach minimizes the likelihood of gap formation and instability, resulting in fewer reoperations. Ultimately, it not only enhances the quality of life for patients but also saves them both time and money on additional surgical procedures.

Dr Siripong emphasized that every surgery, regardless of the surgeon's skill or experience, remains a learning experience. He acknowledged the continual learning process in the field of surgery. While treatment protocols may be well-established, the variable factor is the patients themselves. Each patient is unique, and surgeons and the operating room team must continuously adapt and learn together to provide the best possible care.

Ideal future medical advances in knee replacement

When asked what his wish list for future advances in knee replacement is, Dr Siripong promptly responded, “Customized artificial knee joints designed for each patient.”

Highly skilled surgeons, when combined with robotic surgical assistants, contribute to enhanced precision in bone resection for knee joint resurfacing, facilitating the selection of the most appropriate knee replacement prosthesis for patients. While the current market offers knee prostheses in increasingly precise size gradations, they are not individually customized to achieve a perfect fit for each patient. Consequently, there remains the potential for instability or dislocation of knee replacement implants. The surgeon must adapt and ensure the bone resection aligns seamlessly with the selected implant. 

Dr Siripong noted, “If knee prostheses were tailored-made for each patient, knee replacement surgeries would become more straightforward. Patients would receive a personalized prosthesis, which could significantly enhance the long-term success of the procedure.”

Guidelines for Maintaining Knee Joint Health, as Advised by an Orthopedic Surgeon

Dr Siripong commenced with fundamental principles for knee joint care, stating, “First, it is essential to prioritize our overall health, maintain well-balanced and nutritious diets, and engage in regular exercise.”

He recommended aerobic exercise, emphasizing the importance of patients with preexisting medical conditions following their doctors' guidelines and making specific lifestyle adjustments to reduce the risk of knee osteoarthritis:

• Maintain a healthy body weight to alleviate excessive stress on the knees.
• Avoid activities that involve bending the knees beyond 100 degrees, such as sitting cross-legged or squatting with fully flexed knees, as these actions can impose undue pressure on the knee joints.
• If you have arthritis or rheumatoid arthritis, adhere to your doctor's recommendations.
• Seek immediate medical attention for any injury that could result in fractures or ligament tears.
• Strengthen the muscles surrounding the knees to provide additional support.

Nevertheless, Dr Siripong emphasized that many factors play a role in causing knee osteoarthritis. For individuals who cannot entirely avoid postures involving knee bending but desire to postpone the onset of this degenerative joint condition, he recommended adhering to the other lifestyle adjustments mentioned previously.

“Knee osteoarthritis is a degenerative condition that, once established, cannot be reversed or cured. Currently, no medications or dietary options are available for curing knee osteoarthritis. Instead, physicians can focus on delaying its progression, alleviating symptoms, and pain, and, in some cases, performing replacement surgery to restore patients' quality of life.”

Knee replacement surgery not only enhances the well-being of patients but also enables them to regain their previous levels of mobility and physical activity, ultimately contributing to improved overall health. This surgical procedure is localized, with the added benefit of positively impacting the patient's overall health.

As a result, a robotic surgical assistant has become one of the most dependable surgical techniques. The future is here, and thanks to advanced technology, achieving a higher quality of life is more attainable than ever.